Provider Demographics
NPI:1720048499
Name:WEBER, THERESA SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:SUZANNE
Last Name:WEBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:SUZANNE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:205 W WINDCREST ST STE 310
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4478
Mailing Address - Country:US
Mailing Address - Phone:830-997-2191
Mailing Address - Fax:830-997-8202
Practice Address - Street 1:205 W WINDCREST ST STE 310
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4478
Practice Address - Country:US
Practice Address - Phone:830-997-2191
Practice Address - Fax:830-997-8202
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ87142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ320OtherBCBS
TX113481904Medicaid
TX8AJ320OtherBCBS
TX113481904Medicaid