Provider Demographics
NPI:1023017530
Name:ORPHANIDES, TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:ORPHANIDES
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5617
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR STE 2B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-549-0736
Practice Address - Fax:321-952-2330
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME151443207RG0100X
PAMD032895E207RG0100X
WV25042207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111445000Medicaid
FLN7309OtherFL HF MEDICARE
WV3810024307Medicaid
PA0012965350001Medicaid
PA187526OtherPA BLUE SHIELD
FLN7309OtherFL HF MEDICARE
WVWV1814AOtherMEDICARE PTAN