=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871576157
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY JOSEPH MANDA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2005
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14055 RIVEREDGE DR STE 250
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33637-2141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-929-5451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14055 RIVEREDGE DR STE 250
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33637-2141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-929-5451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 24407
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 036119561
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | ME124662
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------