Provider Demographics
NPI:1538362348
Name:MANAX, TERESA (MD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MANAX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:4545 FULLER DR
Practice Address - Street 2:STE 345
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6530
Practice Address - Country:US
Practice Address - Phone:972-870-5511
Practice Address - Fax:972-870-5512
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD49714Medicare UPIN