Basic Information
| Provider Information | |||||||||
| NPI: | 1861469876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 WHITE OAK | ||||||||
| Address2: | PROFESSIONAL CENTER | ||||||||
| City: | VINCENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457845638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406782374 | ||||||||
| FaxNumber: | 7406788139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 09/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-05-1719 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0591417 | 05 | OH | MEDICAID | 000000699780 | 01 | OH | ANTHEM | OTHER | 0053963000 | 05 | WV | MEDICAID | 000000678715 | 01 | OH | ANTHEM | OTHER |