Provider Demographics
NPI:1982609582
Name:VACHERESSE, THERESA LYNN (DPM)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:LYNN
Last Name:VACHERESSE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 W COSHOCTON ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43031-9587
Mailing Address - Country:US
Mailing Address - Phone:614-901-0000
Mailing Address - Fax:614-901-4117
Practice Address - Street 1:2525 TILLER LN
Practice Address - Street 2:SUITE 105
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-2267
Practice Address - Country:US
Practice Address - Phone:614-901-0000
Practice Address - Fax:614-901-4117
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003295213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2305991Medicaid
OH2305991Medicaid
OHU88604Medicare UPIN
OH4067254Medicare PIN
OH4740820001Medicare NSC