Provider Demographics
NPI:1245243138
Name:ANDERSON, TIMOTHY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:ANDERSON
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 1:3955 PARKLAWN AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5655
Mailing Address - Country:US
Mailing Address - Phone:952-831-1944
Mailing Address - Fax:952-278-6947
Practice Address - Street 1:501 E NICOLLET BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6732
Practice Address - Country:US
Practice Address - Phone:952-898-5900
Practice Address - Fax:952-898-5914
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30239208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN416282000Medicaid
MNFP9020802010OtherPREFERRED ONE
MN13183ANOtherBC/BS
MN1211637OtherMEDICA
MN416282000Medicaid
MNFP9020802010OtherPREFERRED ONE