Provider Demographics
NPI:1831160191
Name:DOMERS, THERESA (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:DOMERS
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 1:172 W WOODGLEN RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:172 W WOODGLEN RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5305
Practice Address - Country:US
Practice Address - Phone:864-278-8542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2014-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22953207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20051869OtherSELECT HEALTH
SC189204OtherMEDCOST
SC229531Medicaid
NC5902063Medicaid
SC5024654OtherAETNA
SCP00313937Medicare PIN
SC5024654OtherAETNA
SCG566938510Medicare PIN
SC20051869OtherSELECT HEALTH