Provider Demographics
NPI:1316033459
Name:THEODORE AFFUE, M.D., INC.
Entity Type:Organization
Organization Name:THEODORE AFFUE, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:AFFUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-353-8181
Mailing Address - Street 1:2061 ROSS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-3687
Mailing Address - Country:US
Mailing Address - Phone:760-353-8181
Mailing Address - Fax:760-353-8282
Practice Address - Street 1:2061 ROSS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-3687
Practice Address - Country:US
Practice Address - Phone:760-353-8181
Practice Address - Fax:760-353-8282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58320208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G853200OtherMEDI-CAL
CAG85320Medicare ID - Type Unspecified
CA00G853200OtherMEDI-CAL