Provider Demographics
NPI:1508977992
Name:WALDEN, THERESA A (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:WALDEN
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 1:1015 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-4362
Mailing Address - Country:US
Mailing Address - Phone:847-289-8355
Mailing Address - Fax:847-289-8358
Practice Address - Street 1:1015 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-4362
Practice Address - Country:US
Practice Address - Phone:847-289-8355
Practice Address - Fax:847-289-8358
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-064887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15348Medicare UPIN
NE47068731708Medicaid
IA16115Medicare ID - Type Unspecified
NE47068731777Medicaid
IA1477414Medicaid
D15348Medicare UPIN