Provider Demographics
NPI:1366466039
Name:HEATLY, TERESA CAROL (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:CAROL
Last Name:HEATLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5151 E BROADWAY RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1346
Mailing Address - Country:US
Mailing Address - Phone:480-290-7000
Mailing Address - Fax:602-254-6840
Practice Address - Street 1:5151 E BROADWAY RD STE 107
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1346
Practice Address - Country:US
Practice Address - Phone:480-290-7000
Practice Address - Fax:480-325-3461
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3600-320207RP1001X, 207RP1001X
AZ23465207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ23465OtherLICENSE
AZ318677Medicaid
WI100258873Medicaid