MEDICARE: TERESITA A CLAR DE JESUS MD

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	207R00000X	Internal Medicine Physician	MD00037685	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457304347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESITA A CLAR DE JESUS MD

Provider Business Mailing Address
First Line	:	7203 W DESCHUTES AVE
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336-7777
Country	:	US
Telephone Number	:	509-737-1880
Fax Number	:	509-737-1879

Provider Business Practice Location Address
First Line	:	521 N YOUNG ST
Second Line	:	KGH MEDICAL MALL
City	:	KENNEWICK
State	:	WA
Zip	:	99336-7806
Country	:	US
Telephone Number	:	509-585-5222
Fax Number	:	509-585-5271

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/12/2010

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