Healthcare Provider Details

I. General information

NPI: 1003938366
Provider Name (Legal Business Name): THERESA A BOYLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 MAGNOLIA DR MOFFITT CANCER CENTER
TAMPA FL
33612
US

IV. Provider business mailing address

16365 ASHINGTON PARK DR
TAMPA FL
33647-2638
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-4673
  • Fax:
Mailing address:
  • Phone: 720-314-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License NumberME 126385
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number42191
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: