Provider Demographics
NPI:1891875274
Name:THACKER, TERESA YVONNE (MD)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:YVONNE
Last Name:THACKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TERESA
Other - Middle Name:YVONNE
Other - Last Name:THACKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5352
Mailing Address - Fax:
Practice Address - Street 1:108 HOUSTON ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-2455
Practice Address - Country:US
Practice Address - Phone:540-463-7628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0053757000Medicaid
WV001721893OtherBCBS
WV080174378OtherTRAVLERS MEDICARE
WVF65772Medicare UPIN
WV0746654Medicare PIN