Provider Demographics
NPI:1326084856
Name:DOCU, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:DOCU
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 1:5750 MOSHOLU AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-2206
Mailing Address - Country:US
Mailing Address - Phone:718-601-0627
Mailing Address - Fax:718-601-0367
Practice Address - Street 1:506 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-2049
Practice Address - Country:US
Practice Address - Phone:212-568-0553
Practice Address - Fax:212-568-5244
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182886207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01189151Medicaid
NYE48898Medicare UPIN
NYWWP771Medicare PIN