Provider Demographics
NPI:1467767541
Name:THEODORE E. STAAHL MD INC
Entity Type:Organization
Organization Name:THEODORE E. STAAHL MD INC
Other - Org Name:MD LASER CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR/OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:STAAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-577-5700
Mailing Address - Street 1:1329 SPANOS CT
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2806
Mailing Address - Country:US
Mailing Address - Phone:209-577-5700
Mailing Address - Fax:209-577-5968
Practice Address - Street 1:1329 SPANOS CT
Practice Address - Street 2:SUITE A-1
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2806
Practice Address - Country:US
Practice Address - Phone:209-577-5700
Practice Address - Fax:209-577-5968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37452261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty