Provider Demographics
NPI:1679679831
Name:GERDIS, TIMOTHY ALLEN (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:GERDIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-222-7010
Mailing Address - Fax:515-222-7037
Practice Address - Street 1:1601 NW 114TH STREET
Practice Address - Street 2:SUITE 255
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7036
Practice Address - Country:US
Practice Address - Phone:515-222-7010
Practice Address - Fax:515-222-7037
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-03245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAH12269Medicare UPIN
IAP00641722OtherRAILROAD MEDICARE PART B
IA546830004Medicare PIN
IA546840003Medicare PIN
IA15416Medicare ID - Type Unspecified
IA0195701Medicaid