Provider Demographics
NPI:1083635189
Name:THERESA PARDOE D.O.
Entity Type:Organization
Organization Name:THERESA PARDOE D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PARDOE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:414-545-1120
Mailing Address - Street 1:9305 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1541
Mailing Address - Country:US
Mailing Address - Phone:414-545-1120
Mailing Address - Fax:414-545-2505
Practice Address - Street 1:9305 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1541
Practice Address - Country:US
Practice Address - Phone:414-545-1120
Practice Address - Fax:414-545-2505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2007-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31462700Medicaid
479701014009OtherBLUE CROSS