Provider Demographics
NPI:1023180320
Name:CUMPSTONE, THERESA J (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:J
Last Name:CUMPSTONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 KINGSLEY AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4490
Mailing Address - Country:US
Mailing Address - Phone:904-215-7015
Mailing Address - Fax:
Practice Address - Street 1:1665 KINGSLEY AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4490
Practice Address - Country:US
Practice Address - Phone:904-215-7015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103838207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTRN8845OtherTRAINING LICENSE NUMBER