Provider Demographics
NPI:1669426490
Name:BOHAN, TIMOTHY P (PHD,MD,PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:BOHAN
Suffix:
Gender:M
Credentials:PHD,MD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 FANNIN STREET
Mailing Address - Street 2:SUITE 2740
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1539
Mailing Address - Country:US
Mailing Address - Phone:713-621-4422
Mailing Address - Fax:713-621-4055
Practice Address - Street 1:6400 FANNIN STREET
Practice Address - Street 2:SUITE 2740
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1539
Practice Address - Country:US
Practice Address - Phone:713-621-4422
Practice Address - Fax:713-621-4055
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH37842080P0008X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0009ATOtherBLUECROSS BLUE SHIELD TX
TX136295612Medicaid
TX136295601Medicaid
TX0009ATOtherBLUECROSS BLUE SHIELD TX