Provider Demographics
NPI:1700907789
Name:COLE, THERESA ANN (DO)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:COLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:1650 SKYLYN DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1047
Mailing Address - Country:US
Mailing Address - Phone:843-253-8100
Mailing Address - Fax:
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:SUITE 3002
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4305
Practice Address - Country:US
Practice Address - Phone:814-534-9194
Practice Address - Fax:814-534-5847
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOT010330208600000X
SC11132086S0129X, 208600000X
PAOS0138732086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC011138Medicaid
SC011138Medicaid