Provider Demographics
NPI:1366499329
Name:TIENSTRA, JOSEPH E (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:E
Last Name:TIENSTRA
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 1:8791 CONFERENCE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-5822
Mailing Address - Country:US
Mailing Address - Phone:239-938-3506
Mailing Address - Fax:
Practice Address - Street 1:63 BARKLEY CIR
Practice Address - Street 2:STE. 100 & 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4514
Practice Address - Country:US
Practice Address - Phone:239-938-3500
Practice Address - Fax:239-278-0055
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00450662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300064841OtherRR MEDICARE
205472OtherAMERIGROUP
0004093006OtherAETNA
ME45066OtherFL WC CERTIFICATION
FLO36234400Medicaid
36420OtherBCBSFL
FL36420TMedicare PIN
FL36420QMedicare ID - Type UnspecifiedFL RAD CONSULT
FLO36234400Medicaid
D62351Medicare UPIN
FL300127796Medicare ID - Type UnspecifiedRR FL RAD CONSULT