Basic Information
| Provider Information | |||||||||
| NPI: | 1548562986 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THOMAS E. TESKE, M.D., INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1745 SOUTH IMPERIAL AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603374100 | ||||||||
| FaxNumber: | 7603374101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1745 SOUTH IMPERIAL AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603374100 | ||||||||
| FaxNumber: | 7603374101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2010 | ||||||||
| LastUpdateDate: | 11/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | TESKE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7603374100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | G65518 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00G655181 | 05 | CA | MEDICAID |