Provider Demographics
NPI:1518091107
Name:TERESA LONGORIA MD LLC
Entity Type:Organization
Organization Name:TERESA LONGORIA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGORIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-325-6633
Mailing Address - Street 1:2102 N COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2831
Mailing Address - Country:US
Mailing Address - Phone:520-325-6633
Mailing Address - Fax:520-325-6644
Practice Address - Street 1:2102 N COUNTRY CLUB RD
Practice Address - Street 2:SUITE 4
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2831
Practice Address - Country:US
Practice Address - Phone:520-325-6633
Practice Address - Fax:520-325-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18725261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTIN