Provider Demographics
NPI:1730149816
Name:SMITH, TERESA L (MD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:L
Last Name:SMITH
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 E BELLEFONTAINE RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:IN
Practice Address - Zip Code:46742-9352
Practice Address - Country:US
Practice Address - Phone:260-488-2211
Practice Address - Fax:260-488-3046
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057213A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200452930AMedicaid
INM400059105Medicare PIN
INH89804Medicare UPIN