Provider Demographics
NPI:1508882457
Name:SCHOCK, THEODORE H (DO)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:H
Last Name:SCHOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:657 S MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2533
Mailing Address - Country:US
Mailing Address - Phone:815-229-9900
Mailing Address - Fax:815-229-9953
Practice Address - Street 1:657 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2533
Practice Address - Country:US
Practice Address - Phone:815-229-9900
Practice Address - Fax:815-229-9953
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-096167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G81594Medicare UPIN