Provider Demographics
NPI:1871576157
Name:MANDA, TIMOTHY JOSEPH (MD)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:MANDA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14055 RIVEREDGE DR STE 250
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-2141
Mailing Address - Country:US
Mailing Address - Phone:813-929-5451
Mailing Address - Fax:
Practice Address - Street 1:14055 RIVEREDGE DR STE 250
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33637-2141
Practice Address - Country:US
Practice Address - Phone:813-929-5451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK244072085R0202X
IL0361195612085R0202X
FLME1246622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200056620AMedicaid
OKI134917Medicare UPIN
OK248521306AMedicare PIN
P00451692Medicare PIN
ILK48152Medicare PIN