Healthcare Provider Details

I. General information

NPI: 1700853322
Provider Name (Legal Business Name): TIMOTHY J. HENRIKSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 E 138TH STE B
FISHERS IN
46037-0051
US

IV. Provider business mailing address

3600 W BETHEL AVE
MUNCIE IN
47304-5407
US

V. Phone/Fax

Practice location:
  • Phone: 800-622-6575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01050725A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: