Provider Demographics
NPI:1902872518
Name:THEOBALD, TERESA F (OD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:F
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4000
Mailing Address - Country:US
Mailing Address - Phone:218-727-6400
Mailing Address - Fax:218-464-4277
Practice Address - Street 1:3308 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4000
Practice Address - Country:US
Practice Address - Phone:218-727-6400
Practice Address - Fax:218-464-4277
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410036000OtherRAILROAD MEDICARE
FM6C247THOtherBCBS & ATRIUM
MN6C247THOtherFIRST PLAN MINNESOTA
MN114513OtherUCARE
MN850527600Medicaid
MN897821009672OtherPREFERRED ONE
MN2207595OtherMEDICA
MNA62871009672OtherPREFERRED ONE
MN2203073OtherMEDICA
MN6C247THOtherFIRST PLAN MINNESOTA
MNA62871009672OtherPREFERRED ONE
MN850527600Medicaid