Provider Demographics
NPI:1972592087
Name:ALICEA, TERESITA (MD)
Entity type:Individual
Prefix:DR
First Name:TERESITA
Middle Name:
Last Name:ALICEA
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 1:3070 DYER BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7839
Mailing Address - Country:US
Mailing Address - Phone:407-932-7930
Mailing Address - Fax:407-932-7935
Practice Address - Street 1:3070 DYER BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7839
Practice Address - Country:US
Practice Address - Phone:407-932-7930
Practice Address - Fax:407-932-7935
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67925208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252839800Medicaid
E86202Medicare UPIN