Provider Demographics
NPI:1902880602
Name:DUCKETT, TIMOTHY GEORGE
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GEORGE
Last Name:DUCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1715
Mailing Address - Country:US
Mailing Address - Phone:419-893-5591
Mailing Address - Fax:419-893-0162
Practice Address - Street 1:999 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1715
Practice Address - Country:US
Practice Address - Phone:419-893-5591
Practice Address - Fax:419-893-0162
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060405208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0991306Medicaid
OH0991306Medicaid
OHDU0764241Medicare ID - Type Unspecified