Provider Demographics
NPI:1851335988
Name:ANDERSON, TY RESO (DO)
Entity type:Individual
Prefix:
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:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 66TH ST N STE 206
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-2101
Mailing Address - Country:US
Mailing Address - Phone:727-541-0323
Mailing Address - Fax:727-541-0336
Practice Address - Street 1:7800 66TH ST N STE 206
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2101
Practice Address - Country:US
Practice Address - Phone:727-541-0323
Practice Address - Fax:727-541-0336
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2025-11-12
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