Provider Demographics
NPI:1417940628
Name:ROMANA, TERESITA (MD)
Entity Type:Individual
Prefix:
First Name:TERESITA
Middle Name:
Last Name:ROMANA
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 1:701 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WILD ROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54984-6901
Mailing Address - Country:US
Mailing Address - Phone:920-622-5560
Mailing Address - Fax:920-622-5598
Practice Address - Street 1:701 GROVE AVE
Practice Address - Street 2:
Practice Address - City:WILD ROSE
Practice Address - State:WI
Practice Address - Zip Code:54984-6901
Practice Address - Country:US
Practice Address - Phone:920-622-5560
Practice Address - Fax:920-622-4198
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24867-020207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31371400Medicaid
WI001500513Medicare ID - Type Unspecified
WIB85200Medicare UPIN