Provider Demographics
NPI:1477996502
Name:SASSALOS, THERESE MARIA (MD)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIA
Last Name:SASSALOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:
Other - Last Name:PERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6777 W MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3013
Mailing Address - Country:US
Mailing Address - Phone:248-325-1091
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HOSPITAL
Practice Address - Street 2:2799 W GRAND BLVD CFP 363
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301102935207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program