Provider Demographics
NPI:1407965619
Name:COVELLO, THERESA A (DO)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:COVELLO
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:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-0208
Mailing Address - Country:US
Mailing Address - Phone:928-475-7219
Mailing Address - Fax:928-475-7370
Practice Address - Street 1:223 CIBEQUE CIRCLE ROAD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550
Practice Address - Country:US
Practice Address - Phone:928-475-7219
Practice Address - Fax:928-475-7370
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010257L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ827321Medicaid
AZH46492Medicare UPIN
AZ8HBW02Medicare ID - Type UnspecifiedID NUMBER FOR HSZ169
AZ8HBW01Medicare ID - Type UnspecifiedID NUMBER FOR HSZ168