Provider Demographics
NPI:1639154875
Name:MUDAY, THERESA AILEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:AILEEN
Last Name:MUDAY
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4501
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22695207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR165468Medicaid
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR0577260001OtherDMERC NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR165468Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER