Provider Demographics
NPI:1427006071
Name:DEFFENBAUGH, TERI A (DO)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:A
Last Name:DEFFENBAUGH
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 1:1125 MADISON ST
Mailing Address - Street 2:OB GYN ASSOCIATES
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5227
Mailing Address - Country:US
Mailing Address - Phone:573-632-5510
Mailing Address - Fax:573-632-5810
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:OB GYN ASSOCIATES
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5510
Practice Address - Fax:573-632-5810
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109200207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
110518OtherBLUE CROSS BLUE SHIELD
277721OtherHEALTHLINK
MO506232909Medicaid
E93924OtherMERCY
MO248040917Medicaid
1060232OtherCCN
1060232OtherFIRST HEALTH
160042443OtherRR MEDICARE
1060232OtherFIRST HEALTH
1060232OtherFIRST HEALTH
E93924Medicare UPIN
MO506232909Medicaid