Provider Demographics
NPI:1790843712
Name:CLOHERTY, TIMOTHY PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:CLOHERTY
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 1:5652 CALLE REAL
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-2317
Mailing Address - Country:US
Mailing Address - Phone:805-967-1539
Mailing Address - Fax:
Practice Address - Street 1:5652 CALLE REAL
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-2317
Practice Address - Country:US
Practice Address - Phone:805-967-1539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG843840207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356409379OtherGROUP NPI
CA00G843840Medicaid
CAG843840OtherMEDICAL BOARD OF CA
CAZZZ42967ZOtherBLUE SHIELD
G85333Medicare UPIN
CA00G843840Medicaid
CAHW8260AMedicare PIN