Provider Demographics
NPI:1295778439
Name:TRAVIS, THERESA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:ANN
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2516 Q ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-4928
Mailing Address - Country:US
Mailing Address - Phone:812-275-3328
Mailing Address - Fax:812-279-5977
Practice Address - Street 1:2516 Q ST
Practice Address - Street 2:SUITE B
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-4928
Practice Address - Country:US
Practice Address - Phone:812-275-3328
Practice Address - Fax:812-279-5977
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036752207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000344070OtherANTHEM BCBS
IND69703Medicare UPIN
IN000000344070OtherANTHEM BCBS