Provider Demographics
NPI:1811949241
Name:CRADDOCK, TERESA M (MD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:M
Last Name:CRADDOCK
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:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9667
Practice Address - Street 1:1515 S CLIFTON AVE
Practice Address - Street 2:STE 400
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2900
Practice Address - Country:US
Practice Address - Phone:316-636-1550
Practice Address - Fax:316-689-9769
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0425326207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100285040NOtherOK MEDICAID
KS100285040NMedicaid
016576028OtherMEDICARE
KS100285040NMedicaid
KS103766Medicare ID - Type Unspecified