Provider Demographics
NPI:1376642413
Name:DAVIS, TERESA E (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9437 S. BELL AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643
Mailing Address - Country:US
Mailing Address - Phone:773-238-5471
Mailing Address - Fax:
Practice Address - Street 1:2875 W 19TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3501
Practice Address - Country:US
Practice Address - Phone:773-484-4831
Practice Address - Fax:773-484-4829
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114569207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114569Medicaid
IL036114569-2Medicaid
IL036114569-2Medicaid