Basic Information
| Provider Information | |||||||||
| NPI: | 1083696371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TELLER | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2115 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373846800 | ||||||||
| FaxNumber: | 9373846939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373846800 | ||||||||
| FaxNumber: | 9373846939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0000X | 35048745 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 207RA0401X | 35048745 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 207RG0300X | 35048745 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 35048745 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0664311 | 05 | OH | MEDICAID | 016801000 | 01 | MAGELLAN | OTHER | 000000330888 | 01 | ANTHEM | OTHER |