Provider Demographics
NPI:1699709139
Name:KINSELLA, TIMOTHY J (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:KINSELLA
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 1:4400 DEERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-8763
Mailing Address - Country:US
Mailing Address - Phone:216-544-5218
Mailing Address - Fax:
Practice Address - Street 1:3175 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6729
Practice Address - Country:US
Practice Address - Phone:941-627-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0739192085R0001X
FL1590502085R0001X
MA396652085R0001X
RIMD131522085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000529630OtherANTHEM
RI9809555OtherAETNA PIN
OH363708OtherWELLCARE
OH1601202OtherUHC
OH2084748Medicaid
OH2138749OtherAETNA
OH000000140688OtherANTHEM
744783OtherBUCKEYE
OH000000224291OtherUNISON
744783OtherBUCKEYE
OH1601202OtherUHC
OH2138749OtherAETNA
OHKI0859656Medicare PIN