Provider Demographics
NPI:1952544199
Name:SUOZZI, THERESA (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SUOZZI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2040 N SHADELAND AVE STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1712
Practice Address - Country:US
Practice Address - Phone:317-355-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT048872207Q00000X
CO45999207Q00000X
IN01072785A207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201202360Medicaid
INP01347744OtherRAILROAD MEDICARE
CT004236346Medicaid
IN266180302Medicare PIN