Provider Demographics
NPI:1043566557
Name:TEDJA, MICHELLE DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DENISE
Last Name:TEDJA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 FANNIN ST STE JJL 495
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:713-500-6645
Mailing Address - Fax:713-500-0527
Practice Address - Street 1:8901 BOONE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-1659
Practice Address - Country:US
Practice Address - Phone:281-454-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2213208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX347829901Medicaid
TXFT4980339OtherDEA REGISTRATION NUMBER
TXQ2213OtherTEXAS MEDICAL BOARD LICENSE