Provider Demographics
NPI:1134148679
Name:PIETRUS, TERESA (MD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:PIETRUS
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 1:4303 WINDEMERE DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1270
Mailing Address - Country:US
Mailing Address - Phone:989-249-0398
Mailing Address - Fax:
Practice Address - Street 1:8680 GRATIOT RD
Practice Address - Street 2:SUITE B
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48609-4885
Practice Address - Country:US
Practice Address - Phone:989-781-3089
Practice Address - Fax:989-781-3209
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITP065998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301147 10Medicaid
MI38-3583399Medicare UPIN
MION26940Medicare ID - Type Unspecified