Provider Demographics
NPI:1336132166
Name:MCCOLLISTER, TERESIA
Entity Type:Individual
Prefix:
First Name:TERESIA
Middle Name:
Last Name:MCCOLLISTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 N FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4232
Mailing Address - Country:US
Mailing Address - Phone:323-254-5221
Mailing Address - Fax:323-254-4618
Practice Address - Street 1:2411 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2218
Practice Address - Country:US
Practice Address - Phone:323-987-2000
Practice Address - Fax:323-987-1448
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 268022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine