Provider Demographics
NPI:1811906084
Name:THUT, TIMOTHY DWAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DWAYNE
Last Name:THUT
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 1:1104 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4304
Mailing Address - Country:US
Mailing Address - Phone:574-533-9945
Mailing Address - Fax:574-534-0411
Practice Address - Street 1:1811 CHARLTON CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6464
Practice Address - Country:US
Practice Address - Phone:574-534-8200
Practice Address - Fax:574-534-0411
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN145760AMedicare ID - Type Unspecified
INB28616Medicare UPIN