Provider Demographics
NPI:1679553952
Name:MAYHARTLE, THERESA (DO)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MAYHARTLE
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 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:12805 ESCANABA DR
Practice Address - Street 2:SUITE 2
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-8628
Practice Address - Country:US
Practice Address - Phone:517-367-5520
Practice Address - Fax:517-367-5521
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011364207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI252503OtherHEALTH ADVANTAGE NETWORK
MI01795OtherAETNA
MI0700186OtherPHYSICIANS HEALTH PLAN
MI252503OtherMCLAREN HEALTH PLAN
MI1651913484OtherBLUE CROSS BLUE SHIELD
MI4154702Medicaid
MIG10710OtherHEALTH NET FEDERAL SERVIC
MI1651913484OtherBLUE CROSS BLUE SHIELD
MIG10710OtherHEALTH NET FEDERAL SERVIC