Provider Demographics
NPI:1245218478
Name:CHROBAK, THEODORE DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:DOUGLAS
Last Name:CHROBAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-5856
Mailing Address - Country:US
Mailing Address - Phone:330-386-6339
Mailing Address - Fax:330-386-1224
Practice Address - Street 1:332 W 6TH ST
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2812
Practice Address - Country:US
Practice Address - Phone:330-386-6339
Practice Address - Fax:330-386-1224
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006156C207Q00000X, 2083X0100X
PA05008296L207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2080555Medicaid
080192335OtherRAILROAD MEDICARE
G25092Medicare UPIN
OH0856213Medicare PIN