1073518577 NPI number — DR. DAVID A THEODORO M.D.

Table of content: DR. DAVID A THEODORO M.D. (NPI 1073518577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073518577 NPI number — DR. DAVID A THEODORO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THEODORO
Provider First Name:
DAVID
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1073518577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
04/05/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23666
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39225-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-200-2780
Provider Business Mailing Address Fax Number:
601-200-2788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12255 DE PAUL DR NORTH BLDG
Provider Second Line Business Practice Location Address:
STE 260
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-647-8269
Provider Business Practice Location Address Fax Number:
314-646-1700
Provider Enumeration Date:
06/20/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  118293 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: 036095641 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: 28104 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036056372 . This is a "SUBSTANCE CONTROL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0360957641 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1102596 . This is a "BNDD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 036056372 . This is a "LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 118293 . This is a "LICENSE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 036095641 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".