Provider Demographics
NPI:1619932639
Name:KING, TERESA A (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:KING
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 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:3111 GUNDERSEN DR
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8447
Practice Address - Country:US
Practice Address - Phone:608-775-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42463-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34011000Medicaid
WI8045OtherDEAN HEALTH INSURANCE
WI1034904OtherPHYSICIANS PLUS
WI004957155Medicare PIN
WI008913215Medicare PIN
WI34011000Medicaid
WI110230059Medicare PIN