Provider Demographics
NPI:1932127933
Name:HOM, THERESA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARIE
Last Name:HOM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HIGH ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-4044
Mailing Address - Country:US
Mailing Address - Phone:614-840-0380
Mailing Address - Fax:614-840-0385
Practice Address - Street 1:1000 HIGH ST
Practice Address - Street 2:SUITE I
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-4044
Practice Address - Country:US
Practice Address - Phone:614-840-0380
Practice Address - Fax:614-840-0385
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004010207Q00000X
OH340004010204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA16778Medicare UPIN
9320121Medicare ID - Type Unspecified