Provider Demographics
NPI:1407111461
Name:SEVILIS, THERESA BETH (DO)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:BETH
Last Name:SEVILIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:GALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11215 METRO PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1206
Mailing Address - Country:US
Mailing Address - Phone:239-208-2212
Mailing Address - Fax:239-208-3994
Practice Address - Street 1:11215 METRO PKWY STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1206
Practice Address - Country:US
Practice Address - Phone:239-208-2212
Practice Address - Fax:239-208-3994
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010237122084N0400X
MO20200055552084N0400X
MS257332084N0400X
TXTM007712084N0400X
CA20A124902084N0400X
NC2015-020192084N0400X
PAOS0196832084N0400X
ORDO1909682084N0400X
NY293822-12084N0400X
OH34.0131782084N0400X
ND152442084N0400X
NH190932084N0400X
FLOS150692084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3116053Medicaid