Provider Demographics
NPI:1164163051
Name:MANTOOTH, THERESA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ELIZABETH
Last Name:MANTOOTH
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 1:107 GILL ST
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-2672
Mailing Address - Country:US
Mailing Address - Phone:865-379-4210
Mailing Address - Fax:865-379-4215
Practice Address - Street 1:107 GILL ST
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2672
Practice Address - Country:US
Practice Address - Phone:865-379-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN74831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine