Provider Demographics
NPI:1073518577
Name:THEODORO, DAVID A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:THEODORO
Suffix:
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-2780
Mailing Address - Fax:601-200-2788
Practice Address - Street 1:12255 DE PAUL DR NORTH BLDG
Practice Address - Street 2:STE 260
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-647-8269
Practice Address - Fax:314-646-1700
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2020-08-27
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MO118293208G00000X
IL036095641208G00000X
MS28104208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056372OtherSUBSTANCE CONTROL
MO0360957641Medicaid
MO1102596OtherBNDD
IL036056372OtherLICENSE
MO118293OtherLICENSE
IL036095641Medicaid
ILF84702Medicare UPIN
MO1102596OtherBNDD
MO0360957641Medicaid
MO118293OtherLICENSE