1265481907 NPI number — TERESA ALLYN PODGORSKI P.A.

Table of content: TERESA ALLYN PODGORSKI P.A. (NPI 1265481907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265481907 NPI number — TERESA ALLYN PODGORSKI P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PODGORSKI
Provider First Name:
TERESA
Provider Middle Name:
ALLYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265481907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17095 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HESPERIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92345-6004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-241-6666
Provider Business Mailing Address Fax Number:
760-241-7575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12550 HESPERIA ROAD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-241-6666
Provider Business Practice Location Address Fax Number:
760-241-7575
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  PA15693 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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