Healthcare Provider Details

I. General information

NPI: 1679554133
Provider Name (Legal Business Name): TIMOTHY G CORNITIUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N 14TH AVE STE 104
DODGE CITY KS
67801-2367
US

IV. Provider business mailing address

1861 N ROCK RD STE 310
WICHITA KS
67206-1264
US

V. Phone/Fax

Practice location:
  • Phone: 620-225-8865
  • Fax: 620-225-8866
Mailing address:
  • Phone: 316-612-1833
  • Fax: 316-612-2420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0424553
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: