MEDICARE: DR. THERESA LYNN DISE 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	208000000X	Pediatrics Physician	07313R	LA

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	:	1518059146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA LYNN DISE MD

Provider Business Mailing Address
First Line	:	1430 TULANE AVE
Second Line	:	SL-37
City	:	NEW ORLEANS
State	:	LA
Zip	:	70112-2632
Country	:	US
Telephone Number	:	504-988-5001
Fax Number	:	504-988-9099

Provider Business Practice Location Address
First Line	:	200 BROADWAY ST
Second Line	:	SUITE 230
City	:	NEW ORLEANS
State	:	LA
Zip	:	70118-3557
Country	:	US
Telephone Number	:	504-988-9000
Fax Number	:	504-988-9099

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

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	06/20/2011

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