Provider Demographics
NPI:1255480067
Name:ASGEIRSSON, THEODOR (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODOR
Middle Name:
Last Name:ASGEIRSSON
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 1:421 S BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2102
Mailing Address - Country:US
Mailing Address - Phone:616-225-8667
Mailing Address - Fax:
Practice Address - Street 1:421 S BALDWIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2102
Practice Address - Country:US
Practice Address - Phone:616-225-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217561208600000X
CAA112879208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery