Provider Demographics
NPI:1639120298
Name:THEESFELD, DANIEL R
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:THEESFELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5145
Mailing Address - Country:US
Mailing Address - Phone:903-753-7333
Mailing Address - Fax:903-753-4849
Practice Address - Street 1:3217 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5145
Practice Address - Country:US
Practice Address - Phone:903-753-7333
Practice Address - Fax:903-753-4849
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3712207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0046KAOtherBLUE CROSS ID
TX0046KAOtherBLUE CROSS ID
TXF55024Medicare UPIN
TX6589710001Medicare NSC
TX6487930001Medicare NSC
TX00858HMedicare PIN
TX612933Medicare PIN
TX6589710001Medicare NSC
TX612933Medicare PIN
TX00858HMedicare PIN