Individual
DR. MICHAEL R THEOBALD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
14551 HOPE CENTER LOOP STE 100, FORT MYERS, FL 33912-4705
(239) 936-2316
(239) 834-6106
Mailing address
3660 BROADWAY, FORT MYERS, FL 33901-8005
(239) 425-4745
(239) 834-6106
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
ME73419
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
252181400
—
FL
01
—
300085120
RR MEDICARE
FL
01
—
300085121
RR MEDICARE
FL
Enumeration date
08/19/2005
Last updated
02/13/2024
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