MEDICARE: DANIEL R THEESFELD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	J3712	TX
2	208VP0014X	Interventional Pain Medicine Physician	J3712	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0046KA	OTHER	TX	BLUE CROSS ID

General Provider Information

NPI Number	:	1639120298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL R THEESFELD

Provider Business Mailing Address
First Line	:	3217 N 4TH ST
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-5145
Country	:	US
Telephone Number	:	903-753-7333
Fax Number	:	903-753-4849

Provider Business Practice Location Address
First Line	:	3217 4TH ST
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-5145
Country	:	US
Telephone Number	:	903-753-7333
Fax Number	:	903-753-4849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/21/2022

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Directions to “ DANIEL R THEESFELD ” Practice Location

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