Provider Demographics
NPI:1174543342
Name:WHITEUS, TIMOTHY (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:WHITEUS
Suffix:
Gender:M
Credentials:MD
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 351127
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-6027
Mailing Address - Country:US
Mailing Address - Phone:313-629-5140
Mailing Address - Fax:
Practice Address - Street 1:13134 BROADSTREET AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3252
Practice Address - Country:US
Practice Address - Phone:313-629-5140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406556207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104632631Medicaid
MI0826726Medicare ID - Type Unspecified