Provider Demographics
NPI:1700885605
Name:VAIL, THERESA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:VAIL
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 1:606 S FLEISHEL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2012
Mailing Address - Country:US
Mailing Address - Phone:903-595-5500
Mailing Address - Fax:903-595-5506
Practice Address - Street 1:606 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2012
Practice Address - Country:US
Practice Address - Phone:903-595-5500
Practice Address - Fax:903-595-5506
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2014-11-20
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
TXL06722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0392920-03Medicaid
TX731682660OtherTAX ID
TX8AJ103OtherBCBS
TXP00039903OtherRAILROAD MEDICARE
TXH19391Medicare UPIN
TX0392920-03Medicaid