Provider Demographics
NPI:1316966906
Name:VETTESE, THERESA (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:VETTESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5972
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:50 E CANFIELD
Practice Address - Street 2:GENERAL MEDICINE AMBULATORY PRACTICE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1804
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-966-7305
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301057647207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630547Medicare PIN