Provider Demographics
NPI:1417954983
Name:MICHELL, THEODORE W (DO)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:W
Last Name:MICHELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 PHILADELPHIA PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-1818
Mailing Address - Country:US
Mailing Address - Phone:302-798-0666
Mailing Address - Fax:302-798-2401
Practice Address - Street 1:1320 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-1818
Practice Address - Country:US
Practice Address - Phone:302-798-0666
Practice Address - Fax:302-798-2401
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0000265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000132903Medicaid
DEB66331Medicare UPIN
DE054019T76Medicare ID - Type Unspecified