Provider Demographics
NPI:1497336259
Name:KLUG, THEODORE DICKINSON (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:DICKINSON
Last Name:KLUG
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6057 BEAU PRE N
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-4101
Mailing Address - Country:US
Mailing Address - Phone:901-491-1721
Mailing Address - Fax:
Practice Address - Street 1:800 STANTON L YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5018
Practice Address - Country:US
Practice Address - Phone:405-271-5504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK39923207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program