Provider Demographics
NPI:1184839698
Name:SCHELLATO, TEODORA ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:TEODORA
Middle Name:ANN
Last Name:SCHELLATO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7604 CENTRAL AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2433
Mailing Address - Country:US
Mailing Address - Phone:215-745-4130
Mailing Address - Fax:
Practice Address - Street 1:7604 CENTRAL AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2433
Practice Address - Country:US
Practice Address - Phone:215-745-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2011-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013079208800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA168067OtherMEDICARE UNSPECIFIED
PA3724847000OtherINDEPENDENCE BLUE CROSS
PA1023982290001Medicaid
PA2109882OtherPA BLUE SHIELD