Basic Information
| Provider Information | |||||||||
| NPI: | 1205853876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEETERS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 SOUTH AVE | ||||||||
| Address2: | BOX 15 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146202733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853416780 | ||||||||
| FaxNumber: | 5853418489 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 SOUTH AVE | ||||||||
| Address2: | BOX 15 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146202733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853416780 | ||||||||
| FaxNumber: | 5853418489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 01/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 230645 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 230645 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 02636991 | 05 | NY | MEDICAID |