Provider Demographics
NPI:1134138795
Name:SNODGRASS, TED COLIN (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:COLIN
Last Name:SNODGRASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3133 S SENECA ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-3234
Mailing Address - Country:US
Mailing Address - Phone:316-524-1613
Mailing Address - Fax:316-524-5462
Practice Address - Street 1:3133 S SENECA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-3234
Practice Address - Country:US
Practice Address - Phone:316-524-1613
Practice Address - Fax:316-524-5462
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00111139OtherMEDICARE RAILROAD
KS103345OtherBC/BS
KSF32297Medicare UPIN
KS103345Medicare ID - Type Unspecified