1730304270 NPI number — THEODORE C.DOCU MD, PC

Table of content: (NPI 1730304270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730304270 NPI number — THEODORE C.DOCU MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THEODORE C.DOCU MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730304270
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 FORT WASHINGTON AVE 1F
Provider Second Line Business Mailing Address:
1F
Provider Business Mailing Address City Name:
NEW YORK,NY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10033
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
212-568-0553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 FORT WASHINGTON AVE 1F
Provider Second Line Business Practice Location Address:
1F
Provider Business Practice Location Address City Name:
NEW YORK,NY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10033
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
212-568-0553
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DOCU
Authorized Official First Name:
THEODORE
Authorized Official Middle Name:
COSTA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
212-568-0553

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  182886 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01189151 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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