Provider Demographics
NPI:1093339061
Name:HARROLD, THEODORE RODOLFO
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:RODOLFO
Last Name:HARROLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 WARRENVILLE RD STE 280
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2075
Mailing Address - Country:US
Mailing Address - Phone:630-324-7900
Mailing Address - Fax:
Practice Address - Street 1:880 W CENTRAL RD STE 7100
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2379
Practice Address - Country:US
Practice Address - Phone:224-735-2937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant