Provider Demographics
NPI:1730527318
Name:LODEN, TERESA LORRAINE (DO)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:LORRAINE
Last Name:LODEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:L
Other - Last Name:DIEBAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1337 S SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2046
Mailing Address - Country:US
Mailing Address - Phone:417-967-5435
Mailing Address - Fax:417-967-5503
Practice Address - Street 1:1337 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2046
Practice Address - Country:US
Practice Address - Phone:417-967-5435
Practice Address - Fax:417-967-5503
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1476208000000X
MO2018008048208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D0889777OtherCLIA
MO200053618Medicaid