MEDICARE: TERESITA P DEJOSEF M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	12410	WV

General Provider Information

NPI Number	:	1164410247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESITA P DEJOSEF M.D.

Provider Business Mailing Address
First Line	:	111 LAFAYETTE ST
Second Line	:	SUITE 201
City	:	SAINT MARYS
State	:	WV
Zip	:	26170-1059
Country	:	US
Telephone Number	:	304-684-9409
Fax Number	:	304-684-2440

Provider Business Practice Location Address
First Line	:	111 LAFAYETTE ST
Second Line	:	SUITE 201
City	:	SAINT MARYS
State	:	WV
Zip	:	26170-1059
Country	:	US
Telephone Number	:	304-684-9409
Fax Number	:	304-684-2440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	07/08/2007

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