Provider Demographics
NPI: | 1952393464 |
---|---|
Name: | THEOBALD, MICHAEL R (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MICHAEL |
Middle Name: | R |
Last Name: | THEOBALD |
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: | 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: | 239-834-6106 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-19 |
Last Update Date: | 2024-02-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME73419 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 252181400 | Medicaid | |
FL | 300085121 | Other | RR MEDICARE |
FL | 300085120 | Other | RR MEDICARE |
FL | 300085120 | Other | RR MEDICARE |
FL | 252181400 | Medicaid | |
FL | 42359X | Medicare PIN |