Basic Information
| Provider Information | |||||||||
| NPI: | 1609826650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PISTOCCO | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | BRUCE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 507 | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063559595 | ||||||||
| FaxNumber: | 8063531589 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 S COULTER ST | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063541000 | ||||||||
| FaxNumber: | 8063541200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/24/2010 | ||||||||
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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 | 207L00000X | H4617 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 128918305 | 05 | TX | MEDICAID | 050045042 | 01 | GA | RR MEDICARE | OTHER |