Provider Demographics
NPI:1417056201
Name:THEOBALD, ROGER (AUD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:THEOBALD
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8642
Mailing Address - Country:US
Mailing Address - Phone:208-377-0019
Mailing Address - Fax:208-377-0313
Practice Address - Street 1:1084 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8642
Practice Address - Country:US
Practice Address - Phone:208-377-0019
Practice Address - Fax:208-377-0313
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003402060Medicaid