Provider Demographics
NPI:1689608192
Name:MAHONEY, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:MAHONEY
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 1:1707 GOLD DR S STE 101
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6413
Mailing Address - Country:US
Mailing Address - Phone:701-280-2033
Mailing Address - Fax:701-232-5578
Practice Address - Street 1:1707 GOLD DR S STE 101
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6413
Practice Address - Country:US
Practice Address - Phone:701-280-2033
Practice Address - Fax:701-232-5578
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3622207Q00000X, 208D00000X, 208600000X
MN24007208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND120231OtherUCARE #
ND1700559OtherMEDICA #
ND20698OtherNDBS #
ND2164OtherNDBS #
ND844548OtherAMERICA'S PPO/ARAZ #
ND13390Medicaid
NDND20017469OtherLHS #
ND1700509OtherMEDICA #
ND6508OtherSIOUX VALLEY #
NDDA9011008232OtherPREFERRED ONE #
ND1700509OtherMEDICA #
ND020001354Medicare ID - Type UnspecifiedMN MEDICARE #
ND1700559OtherMEDICA #
ND020017469Medicare ID - Type UnspecifiedRR MEDICARE #