Provider Demographics
NPI:1881766640
Name:GUTSHALL, TIMOTHY R (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:GUTSHALL
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 1:4021 BAYBERRY CT
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-2171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:STE 417
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2350
Practice Address - Country:US
Practice Address - Phone:515-263-5684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25336207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2105098Medicaid
IA3105098Medicaid
IA930039017OtherMEDICARE RAILROAD
IA54696Medicare ID - Type UnspecifiedILH
IA2105098Medicaid
IA3105098Medicaid