Provider Demographics
NPI:1053407452
Name:CONOLOGUE, THERESA (DO)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:CONOLOGUE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SAM PERRY BLVD STE 121
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4465
Mailing Address - Country:US
Mailing Address - Phone:540-899-1600
Mailing Address - Fax:
Practice Address - Street 1:1101 SAM PERRY BLVD STE 121
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4465
Practice Address - Country:US
Practice Address - Phone:540-899-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201892207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology