Provider Demographics
NPI:1750332995
Name:CLOONAN, TIMOTHY G (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:G
Last Name:CLOONAN
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 1:1390 KELLY JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3908
Mailing Address - Country:US
Mailing Address - Phone:719-593-1799
Mailing Address - Fax:719-265-3794
Practice Address - Street 1:3050 N CIRCLE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1175
Practice Address - Country:US
Practice Address - Phone:719-593-1799
Practice Address - Fax:719-265-3794
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO499462085R0202X
IN010470712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200279180Medicaid
OH2271518Medicaid
IN11989OtherPHP
MI4300613100Medicaid
IN000000196823OtherANTHEM
CO42872286Medicaid
IN200279180Medicaid
CO42872286Medicaid
MI4300613100Medicaid
IN191150FMedicare ID - Type Unspecified
IN147380XMedicare ID - Type Unspecified
IN055740AAMedicare ID - Type Unspecified
OH2271518Medicaid
IN11989OtherPHP
COE05859Medicare UPIN
IN194930CMedicare ID - Type Unspecified
IN190320DMedicare ID - Type Unspecified
IN300125945Medicare ID - Type Unspecified