Provider Demographics
NPI:1679647317
Name:WARTHAN, T LYNN (MD)
Entity Type:Individual
Prefix:
First Name:T
Middle Name:LYNN
Last Name:WARTHAN
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 1:4730 NE STALLINGS DRIVE
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965
Mailing Address - Country:US
Mailing Address - Phone:936-564-6107
Mailing Address - Fax:936-564-5124
Practice Address - Street 1:4730 NE STALLINGS DRIVE
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965
Practice Address - Country:US
Practice Address - Phone:936-564-6107
Practice Address - Fax:936-564-5124
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8472207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B27426Medicare UPIN
TX00T542Medicare ID - Type Unspecified