Provider Demographics
NPI:1417992272
Name:LEDERMAN, THEODORE S (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:S
Last Name:LEDERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:2710 SAINT FRANCIS DR
Practice Address - Street 2:SUITE 210
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5619
Practice Address - Country:US
Practice Address - Phone:319-272-5000
Practice Address - Fax:319-272-5282
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2007-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA18607207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0135517Medicaid
IA0135517Medicaid
IA135517Medicare PIN