Provider Demographics
NPI:1235348558
Name:THEODORE, JOSOPH J (MD)
Entity Type:Individual
Prefix:
First Name:JOSOPH
Middle Name:J
Last Name:THEODORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CHATTAHOOCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33224-1000
Mailing Address - Country:US
Mailing Address - Phone:850-663-7661
Mailing Address - Fax:850-663-7331
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-1107
Practice Address - Country:US
Practice Address - Phone:850-663-7661
Practice Address - Fax:850-663-7113
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0049172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD50417Medicare UPIN