Provider Demographics
NPI:1679554133
Name:CORNITIUS, TIMOTHY G (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:CORNITIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1861 N ROCK RD STE 310
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1264
Mailing Address - Country:US
Mailing Address - Phone:316-612-1833
Mailing Address - Fax:316-612-2420
Practice Address - Street 1:2300 N 14TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2367
Practice Address - Country:US
Practice Address - Phone:620-225-8865
Practice Address - Fax:620-225-8866
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2024-02-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS0424553207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100144270AMedicaid
D87125Medicare UPIN
KS100144270AMedicaid