Provider Demographics
NPI:1467537415
Name:HUMPHRY, THEODORE RIGGS (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:RIGGS
Last Name:HUMPHRY
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 1:670 9TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6248
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:1644 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-4342
Practice Address - Country:US
Practice Address - Phone:707-839-2677
Practice Address - Fax:707-839-2747
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33651208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G336510Medicaid
CA00G336510Medicaid