Provider Demographics
NPI:1902822687
Name:OSWALD, THERESA A (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:OSWALD
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 1:945 BETHANY TPKE
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-4041
Mailing Address - Country:US
Mailing Address - Phone:570-470-8071
Mailing Address - Fax:
Practice Address - Street 1:945 BETHANY TPKE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431
Practice Address - Country:US
Practice Address - Phone:570-470-8071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34432-020208100000X
TXN5303208100000X
OH35.129337208100000X
PAMD456608208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32103300Medicaid
WI32103300Medicaid
G00530Medicare UPIN