Provider Demographics
NPI:1508051947
Name:TEETERS, VAN WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:WAYNE
Last Name:TEETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 WATERWAY CT
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2641
Mailing Address - Country:US
Mailing Address - Phone:713-527-8235
Mailing Address - Fax:281-419-7321
Practice Address - Street 1:44 WATERWAY CT
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-2641
Practice Address - Country:US
Practice Address - Phone:713-527-8235
Practice Address - Fax:281-419-7321
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4330174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXUB26896Medicare UPIN