Provider Demographics
NPI:1760496764
Name:WHITLEY, TERESA B (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:B
Last Name:WHITLEY
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 1:1860 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3590
Mailing Address - Country:US
Mailing Address - Phone:707-646-4100
Mailing Address - Fax:707-646-4101
Practice Address - Street 1:1860 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3590
Practice Address - Country:US
Practice Address - Phone:707-646-4100
Practice Address - Fax:707-646-4101
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 65738282N00000X
CA8657381207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA 65738OtherCALIF STATE MED LICENSE