Provider Demographics
NPI:1508943606
Name:DE JESUS-ROETLIN, MARIA THERESA (CLINICAL PHARMACIST)
Entity type:Individual
Prefix:
First Name:MARIA THERESA
Middle Name:
Last Name:DE JESUS-ROETLIN
Suffix:
Gender:F
Credentials:CLINICAL PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 EVENING SONG DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-7644
Mailing Address - Country:US
Mailing Address - Phone:319-330-3154
Mailing Address - Fax:
Practice Address - Street 1:2345 EVENING SONG DR
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-7644
Practice Address - Country:US
Practice Address - Phone:319-330-3154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73902183500000X
IA20452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
420985270OtherFEDERAL ID ASSOC. MEDICAI
IA0015131Medicaid