Provider Demographics
NPI:1083696371
Name:TELLER, DOUGLAS W (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:W
Last Name:TELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3600
Mailing Address - Country:US
Mailing Address - Phone:937-384-6800
Mailing Address - Fax:937-384-6939
Practice Address - Street 1:2115 LEITER RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3600
Practice Address - Country:US
Practice Address - Phone:937-384-6800
Practice Address - Fax:937-384-6939
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048745207RA0000X, 207RA0401X, 207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0664311Medicaid
016801000OtherMAGELLAN
000000330888OtherANTHEM
OH$$$$$$$$$00OtherBWC
016801000OtherMAGELLAN
OH0664311Medicaid
OH$$$$$$$$$010OtherMMOH
0620781Medicare PIN
C03396Medicare UPIN
OH0620787Medicare PIN