Provider Demographics
NPI:1073629929
Name:PAINTER, THEOPHILUS SHICKEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THEOPHILUS
Middle Name:SHICKEL
Last Name:PAINTER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 W 34TH ST
Mailing Address - Street 2:STE 201
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705
Mailing Address - Country:US
Mailing Address - Phone:512-454-5821
Mailing Address - Fax:512-459-9137
Practice Address - Street 1:800 W 34TH ST
Practice Address - Street 2:STE 201
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-454-5821
Practice Address - Fax:512-459-9137
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB9692207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPO82G6118Medicaid
TX0004CNOtherBLUE CROSS
TX82G611Medicare ID - Type Unspecified
TXPO82G6118Medicaid