Basic Information
| Provider Information | |||||||||
| NPI: | 1710977566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 TECHNOLOGY CENTER DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462786013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173285050 | ||||||||
| FaxNumber: | 3177159965 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 TECHNOLOGY CENTER DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462786013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173285050 | ||||||||
| FaxNumber: | 3177159965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01053844A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | Q0417073 | 01 | IN | CMOSHO351158723&352047427 | OTHER | 200427660 | 05 | IN | MEDICAID | 000000492340 | 01 | IN | ANTHEM 203778927 | OTHER | 108054 | 01 | IN | HEALTH ALLIANCE-351158723 | OTHER | 000000260995 | 01 | IN | ANTHEM-351158723 | OTHER | 021382 | 01 | IN | SIHO-351158723 | OTHER | 300139049 | 01 | IN | RR MEDICARE-351158723 | OTHER |