Provider Demographics
NPI:1992878771
Name:DAHL, THERESE B (OD)
Entity type:Individual
Prefix:DR
First Name:THERESE
Middle Name:B
Last Name:DAHL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3659 SOUTH HOPKINS AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780
Mailing Address - Country:US
Mailing Address - Phone:321-264-4264
Mailing Address - Fax:321-264-9433
Practice Address - Street 1:3659 SOUTH HOPKINS AVE
Practice Address - Street 2:SUITE D
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780
Practice Address - Country:US
Practice Address - Phone:321-264-4264
Practice Address - Fax:321-264-9433
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPL1525152W00000X
WI1532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
27596OtherAVESIS
FL078593800Medicaid
114116OtherEYEMED
1213330001OtherDMNS CLEARING HOUSE
180004904OtherRAILROAD MEDICARE
FL078593800Medicaid
180004904OtherRAILROAD MEDICARE
T93898Medicare UPIN