Healthcare Provider Details

I. General information

NPI: 1053336321
Provider Name (Legal Business Name): TIMOTHY H HARTZOG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-224-4635
  • Fax: 540-529-7864
Mailing address:
  • Phone: 540-224-5705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD459676
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101282743
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: