Provider Demographics
NPI:1144606369
Name:KAISER, THEODORE STANTON III (RN, CDOE)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:STANTON
Last Name:KAISER
Suffix:III
Gender:M
Credentials:RN, CDOE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 ALLENS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5010
Mailing Address - Country:US
Mailing Address - Phone:401-444-0400
Mailing Address - Fax:401-444-0468
Practice Address - Street 1:530 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5762
Practice Address - Country:US
Practice Address - Phone:401-415-9500
Practice Address - Fax:401-415-9515
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI32575163W00000X
RIRN32575163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI163W00000XMedicaid
RI163W00000XMedicare Oscar/Certification
RI163W00000XMedicaid