Provider Demographics
NPI:1689625162
Name:HUMPHRIES, TIMOTHY A (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:HUMPHRIES
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 1377
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1377
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:912-384-1470
Practice Address - Street 1:100 DOCTORS DR STE C
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2211
Practice Address - Country:US
Practice Address - Phone:912-384-5832
Practice Address - Fax:912-383-8279
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053461208600000X
GA53641208G00000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA715822455Medicaid
GA715822455Medicaid
GA715822455Medicaid