Healthcare Provider Details

I. General information

NPI: 1629076534
Provider Name (Legal Business Name): TIMOTHY HANS DERSTINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S ALLEN ST SUITE 216
STATE COLLEGE PA
16801-4849
US

IV. Provider business mailing address

PO BOX 1120
LEMONT PA
16851-1120
US

V. Phone/Fax

Practice location:
  • Phone: 814-689-9744
  • Fax: 888-981-8069
Mailing address:
  • Phone: 814-689-9744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD 056013-L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: