Provider Demographics
NPI:1073506234
Name:DAKE, THEODORE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:DAKE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 STAGECOACH TRL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-5134
Mailing Address - Country:US
Mailing Address - Phone:512-392-3398
Mailing Address - Fax:512-392-2890
Practice Address - Street 1:310 STAGECOACH TRL
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5134
Practice Address - Country:US
Practice Address - Phone:512-392-3398
Practice Address - Fax:512-392-2890
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9594174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8M0870OtherBLUE CROSS BLUE SHIELD
TX00FC30Medicare ID - Type Unspecified
TXB22098Medicare UPIN