Provider Demographics
NPI:1649225129
Name:STAMATO, THERESA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:STAMATO
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:1600 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-1521
Practice Address - Country:US
Practice Address - Phone:605-312-1000
Practice Address - Fax:605-312-1001
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35518208000000X
SD47462080P0202X
MN44264208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G11632Medicare UPIN
SDS42167Medicare PIN
SDS101539Medicare PIN
SD470000517Medicare PIN