Provider Demographics
NPI:1649227950
Name:GESTELAND, THERESE J (MD)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:J
Last Name:GESTELAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:J
Other - Last Name:BULLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3200 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9274
Mailing Address - Country:US
Mailing Address - Phone:262-836-7300
Mailing Address - Fax:262-836-7301
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-836-7300
Practice Address - Fax:262-836-7301
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40936-020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32553200Medicaid
WI930074906OtherMEDICARE RAILROAD
WI1649227950Medicaid
WI930074935OtherMEDICARE RAILROAD
WI930074935OtherMEDICARE RAILROAD
WI0070-68655Medicare ID - Type Unspecified