Provider Demographics
NPI:1982644993
Name:FORMANEK, TERI S (MD)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:S
Last Name:FORMANEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HUTCHINGS ST
Mailing Address - Street 2:
Mailing Address - City:WINTERSET
Mailing Address - State:IA
Mailing Address - Zip Code:50273-2109
Mailing Address - Country:US
Mailing Address - Phone:515-462-2373
Mailing Address - Fax:
Practice Address - Street 1:300 W HUTCHINGS ST
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273
Practice Address - Country:US
Practice Address - Phone:515-462-2373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26239207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2083659Medicaid
IAI6312Medicare ID - Type Unspecified
IA2083659Medicaid