Provider Demographics
NPI:1497741375
Name:MCENTEE, THERESA M (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:MCENTEE
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 1:310 ARIZONA ST
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603-1502
Mailing Address - Country:US
Mailing Address - Phone:520-432-1145
Mailing Address - Fax:520-432-1217
Practice Address - Street 1:108 ARIZONA ST
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603-1804
Practice Address - Country:US
Practice Address - Phone:520-432-1145
Practice Address - Fax:520-432-1217
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ432592Medicaid
AZ432592Medicaid
AZ73028Medicare ID - Type Unspecified