Healthcare Provider Details

I. General information

NPI: 1689608192
Provider Name (Legal Business Name): TIMOTHY J MAHONEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 GOLD DR S STE 101
FARGO ND
58103-6413
US

IV. Provider business mailing address

1707 GOLD DR S STE 101
FARGO ND
58103-6413
US

V. Phone/Fax

Practice location:
  • Phone: 701-280-2033
  • Fax: 701-232-5578
Mailing address:
  • Phone: 701-280-2033
  • Fax: 701-232-5578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3622
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24007
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number3622
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number3622
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: