Provider Demographics
NPI:1750824959
Name:TECLAW, MARY ELLEN (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELLEN
Last Name:TECLAW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-4941
Mailing Address - Country:US
Mailing Address - Phone:608-833-0062
Mailing Address - Fax:
Practice Address - Street 1:17495 W CAPITOL DR
Practice Address - Street 2:SUITE D
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2059
Practice Address - Country:US
Practice Address - Phone:262-797-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3440-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist