Provider Demographics
NPI:1033107388
Name:THOLE, HEATHER SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:SUE
Last Name:THOLE
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 1:11948 BALM RIVERVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-6601
Mailing Address - Country:US
Mailing Address - Phone:813-236-9000
Mailing Address - Fax:813-236-9002
Practice Address - Street 1:11948 BALM RIVERVIEW RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-6601
Practice Address - Country:US
Practice Address - Phone:813-236-9000
Practice Address - Fax:813-236-9002
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82918208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262411700Medicaid