Provider Demographics
NPI:1881608966
Name:HILLEY VENSEL, THERESA DAWN (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:DAWN
Last Name:HILLEY VENSEL
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 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-425-4745
Mailing Address - Fax:239-834-6106
Practice Address - Street 1:14551 HOPE CENTER LOOP STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4705
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:239-936-3099
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME858702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54959OtherBCBS
FL276057600Medicaid
FLP00352704OtherRR MEDICARE
FLP00352711OtherRR MEDICARE
FL54959OtherBCBS
FL276057600Medicaid