Provider Demographics
NPI:1912947920
Name:WETHERILL, TIMOTHY F (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:F
Last Name:WETHERILL
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 1:1631 HOSPITAL DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4728
Mailing Address - Country:US
Mailing Address - Phone:505-913-3975
Mailing Address - Fax:505-986-8001
Practice Address - Street 1:1631 HOSPITAL DR
Practice Address - Street 2:SUITE 240
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4728
Practice Address - Country:US
Practice Address - Phone:505-913-3975
Practice Address - Fax:505-986-8001
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0088208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
10020619OtherLOVELACE
NM98708881Medicaid
202007841OtherPRESBYTERIAN HEALTH PLAN
2523396OtherUHC
NMNM001H25OtherBCBS NM
QMYPR0069821OtherMOLINA HEALTHCARE
NM346633806Medicare PIN
10020619OtherLOVELACE