Provider Demographics
NPI:1124031356
Name:YOHAN, THEODORE IPOTE
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:IPOTE
Last Name:YOHAN
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 1:920 E GARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91755-3044
Mailing Address - Country:US
Mailing Address - Phone:626-280-4504
Mailing Address - Fax:626-280-8272
Practice Address - Street 1:920 E GARVEY AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91755-3044
Practice Address - Country:US
Practice Address - Phone:626-280-4504
Practice Address - Fax:626-280-8272
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4886340001Medicare ID - Type Unspecified