Provider Demographics
NPI:1568578326
Name:VALLADARES, THERESA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:LYNN
Last Name:VALLADARES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 E FERGUSON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-2613
Mailing Address - Country:US
Mailing Address - Phone:956-702-0024
Mailing Address - Fax:956-702-0616
Practice Address - Street 1:923 E FERGUSON ST
Practice Address - Street 2:SUITE C
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-2613
Practice Address - Country:US
Practice Address - Phone:956-702-0024
Practice Address - Fax:956-702-0616
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4822207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173167102Medicaid
TX0011MPOtherBCBS PROVIDER #
TX173167101Medicaid
TX742925774OtherTAX ID
TX148012102Medicaid
TX148012102Medicaid
TX173167102Medicaid
TX8E0396Medicare ID - Type Unspecified