Provider Demographics
NPI:1134458524
Name:TEODORO, NOEL C (RSA)
Entity Type:Individual
Prefix:MR
First Name:NOEL
Middle Name:C
Last Name:TEODORO
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16525 W 159TH ST # 140
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-7900
Mailing Address - Country:US
Mailing Address - Phone:708-602-2183
Mailing Address - Fax:815-600-8637
Practice Address - Street 1:333 MADISON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8200
Practice Address - Country:US
Practice Address - Phone:815-725-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000243246ZC0007X
IL238.000243363AS0400X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical