Provider Demographics
NPI:1710970488
Name:VILLASIS, TERESITA (MD)
Entity Type:Individual
Prefix:
First Name:TERESITA
Middle Name:
Last Name:VILLASIS
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 1:1010 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3534
Mailing Address - Country:US
Mailing Address - Phone:269-428-9301
Mailing Address - Fax:
Practice Address - Street 1:310 S FRONT ST
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-1740
Practice Address - Country:US
Practice Address - Phone:269-782-8696
Practice Address - Fax:269-782-0816
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08-0-14-0008-1OtherBCBSM
MI08-0-14-0008-1OtherBCBSM
MIF66250Medicare UPIN