Provider Demographics
NPI:1184688970
Name:GEORGELAS, TIMOTHY JOHN (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:GEORGELAS
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 1888
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:903-453-2541
Practice Address - Street 1:403 W CAMPBELL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3465
Practice Address - Country:US
Practice Address - Phone:972-498-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG21402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
8U5020OtherBCBS
TX8F1669Medicare PIN
8U5020OtherBCBS
TXP00352388Medicare PIN
C16047Medicare UPIN