Provider Demographics
NPI:1255317970
Name:GIFFORD, THEODORE H (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:H
Last Name:GIFFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6388
Mailing Address - Country:US
Mailing Address - Phone:563-582-1881
Mailing Address - Fax:
Practice Address - Street 1:350 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6388
Practice Address - Country:US
Practice Address - Phone:563-582-1881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18406207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0050823Medicaid
28061Medicare ID - Type Unspecified
C44476Medicare UPIN