Provider Demographics
NPI:1790814630
Name:KUNTZ, TIMOTHY C (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
Last Name:KUNTZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1413
Mailing Address - Country:US
Mailing Address - Phone:615-323-9158
Mailing Address - Fax:615-323-9100
Practice Address - Street 1:307 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1413
Practice Address - Country:US
Practice Address - Phone:615-323-9158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2126207Q00000X
TN1484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine