Provider Demographics
NPI: | 1023193075 |
---|---|
Name: | TED HUMPHRY, M.D., INC. |
Entity Type: | Organization |
Organization Name: | TED HUMPHRY, M.D., INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | THEODORE |
Authorized Official - Middle Name: | RIGGS |
Authorized Official - Last Name: | HUMPHRY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 707-822-2441 |
Mailing Address - Street 1: | 827 BAYSIDE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | ARCATA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95521-6403 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 707-822-2441 |
Mailing Address - Fax: | 707-826-1026 |
Practice Address - Street 1: | 827 BAYSIDE RD |
Practice Address - Street 2: | |
Practice Address - City: | ARCATA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95521-6403 |
Practice Address - Country: | US |
Practice Address - Phone: | 707-822-2441 |
Practice Address - Fax: | 707-826-1026 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-10-26 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G33651 | 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Single Specialty |