Provider Demographics
NPI:1851335988
Name:ANDERSON, TY RESO (DO)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:RESO
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5400 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-3833
Mailing Address - Country:US
Mailing Address - Phone:352-277-5305
Mailing Address - Fax:352-616-0926
Practice Address - Street 1:1111 7TH AVE N STE 107
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1348
Practice Address - Country:US
Practice Address - Phone:727-894-6703
Practice Address - Fax:727-894-1430
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15140207Q00000X
FLOS7064207Q00000X
FLOS13386207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G44588Medicare UPIN
FL31327BMedicare ID - Type Unspecified