Provider Demographics
NPI:1124361258
Name:THEIS, MORGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MORGAN
Middle Name:
Last Name:THEIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-1257
Mailing Address - Country:US
Mailing Address - Phone:209-394-7913
Mailing Address - Fax:209-394-9093
Practice Address - Street 1:1140 MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1257
Practice Address - Country:US
Practice Address - Phone:209-394-7913
Practice Address - Fax:209-394-9093
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA133677207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program