Provider Demographics
NPI:1093722480
Name:ENDE, THEODORE (DO)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:ENDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:WARETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08758-1743
Mailing Address - Country:US
Mailing Address - Phone:609-693-1992
Mailing Address - Fax:609-693-1992
Practice Address - Street 1:422 WEST LACEY ROAD
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-2518
Practice Address - Country:US
Practice Address - Phone:609-693-1992
Practice Address - Fax:609-971-3199
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03165000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0659703Medicaid
NJ0659703Medicaid
NJ123723Medicare PIN