Provider Demographics
NPI:1760450522
Name:O'DEA, TERESA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA MARIE
Middle Name:
Last Name:O'DEA
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 1:10670 WEXFORD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3940
Mailing Address - Country:US
Mailing Address - Phone:858-499-2701
Mailing Address - Fax:858-621-4070
Practice Address - Street 1:2001 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2303
Practice Address - Country:US
Practice Address - Phone:619-446-1727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65049208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA65049OtherMD LICENSE