Provider Demographics
NPI:1649262155
Name:TALLON, M TERESA (MD)
Entity type:Individual
Prefix:
First Name:M
Middle Name:TERESA
Last Name:TALLON
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 1:2821 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1668
Mailing Address - Country:US
Mailing Address - Phone:260-497-0602
Mailing Address - Fax:260-497-0657
Practice Address - Street 1:2821 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1668
Practice Address - Country:US
Practice Address - Phone:260-497-0602
Practice Address - Fax:260-497-0657
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039505207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100104150AMedicaid
IN000000089022OtherANTHEM BCBS
IN100104150AMedicaid
191660Medicare ID - Type Unspecified