Provider Demographics
NPI:1154322659
Name:TABER, THEODORE W (DC)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:W
Last Name:TABER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14300 GALLANT FOX LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4003
Mailing Address - Country:US
Mailing Address - Phone:301-352-4500
Mailing Address - Fax:301-352-6510
Practice Address - Street 1:14300 GALLANT FOX LN
Practice Address - Street 2:SUITE 201
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4003
Practice Address - Country:US
Practice Address - Phone:301-352-4500
Practice Address - Fax:301-352-6510
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01943111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCS2410002OtherCAREFIRST BC/BS
MDLR25TAOtherCAREFIRST BCBS OF MD
MD287087OtherMAMSI PROVIDER NUMBER
MD60608903OtherCAREFIRST BCBS OF MD REG#
522247005OtherFEDERAL TAX ID
MD287087OtherMAMSI PROVIDER NUMBER
MDG00379Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER