Provider Demographics
NPI:1629076534
Name:DERSTINE, TIMOTHY HANS (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:HANS
Last Name:DERSTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1120
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:PA
Mailing Address - Zip Code:16851-1120
Mailing Address - Country:US
Mailing Address - Phone:814-689-9744
Mailing Address - Fax:
Practice Address - Street 1:315 S ALLEN ST
Practice Address - Street 2:SUITE 216
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-4849
Practice Address - Country:US
Practice Address - Phone:814-689-9744
Practice Address - Fax:888-981-8069
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 056013-L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G48336Medicare UPIN
904235Medicare ID - Type Unspecified