Provider Demographics
NPI:1457304347
Name:CLAR DE JESUS, TERESITA A (MD)
Entity Type:Individual
Prefix:
First Name:TERESITA
Middle Name:A
Last Name:CLAR DE JESUS
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 1:7203 W DESCHUTES AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7777
Mailing Address - Country:US
Mailing Address - Phone:509-737-1880
Mailing Address - Fax:509-737-1879
Practice Address - Street 1:521 N YOUNG ST
Practice Address - Street 2:KGH MEDICAL MALL
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7806
Practice Address - Country:US
Practice Address - Phone:509-585-5222
Practice Address - Fax:509-585-5271
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037685207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8246712Medicaid
8853339Medicare ID - Type Unspecified
H10201Medicare UPIN