Basic Information
| Provider Information | |||||||||
| NPI: | 1447259965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TESKE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 852 E DANENBERG DR | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922438511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603449951 | ||||||||
| FaxNumber: | 7603441629 | ||||||||
| Practice Location | |||||||||
| Address1: | 852 E DANENBERG DR | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922438511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603522257 | ||||||||
| FaxNumber: | 7603524579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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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 | 2084N0400X | G65518 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00G655181 | 05 | CA | MEDICAID |