Provider Demographics
NPI:1912040288
Name:PRATT, TERESA DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:DIANE
Last Name:PRATT
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1700 CERRILLOS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3026
Mailing Address - Country:US
Mailing Address - Phone:505-946-9361
Mailing Address - Fax:505-946-9413
Practice Address - Street 1:1700 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3554
Practice Address - Country:US
Practice Address - Phone:505-988-9821
Practice Address - Fax:505-983-6243
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24281207Q00000X
CO29045207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114769Medicare ID - Type Unspecified
ORE88664Medicare UPIN