Provider Demographics
NPI:1164423448
Name:ISSEKS, THEODORE N (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:N
Last Name:ISSEKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:THEODORE
Other - Middle Name:N
Other - Last Name:ISSEKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5518 STATE ROUTE 55
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754
Mailing Address - Country:US
Mailing Address - Phone:845-292-3011
Mailing Address - Fax:845-292-1821
Practice Address - Street 1:5518 STATE ROUTE 55
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754
Practice Address - Country:US
Practice Address - Phone:845-292-3011
Practice Address - Fax:845-292-1821
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117110207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00248233Medicaid
NY00248233Medicaid