Provider Demographics
NPI:1518072149
Name:ROGER THEODORE, M.D., P.A.
Entity Type:Organization
Organization Name:ROGER THEODORE, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:THEODORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-583-2200
Mailing Address - Street 1:7505 OSLER DR
Mailing Address - Street 2:SUITE 216
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7736
Mailing Address - Country:US
Mailing Address - Phone:410-583-2200
Mailing Address - Fax:410-583-2273
Practice Address - Street 1:7505 OSLER DR
Practice Address - Street 2:SUITE 216
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7736
Practice Address - Country:US
Practice Address - Phone:410-583-2200
Practice Address - Fax:410-583-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD14165174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8492Medicare ID - Type Unspecified
MDD01231Medicare UPIN