Provider Demographics
NPI:1548572985
Name:JOHN B. THEOBALDS & ASSOCIATE INC
Entity Type:Organization
Organization Name:JOHN B. THEOBALDS & ASSOCIATE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:THEOBALDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-667-8701
Mailing Address - Street 1:3636 16TH ST NW
Mailing Address - Street 2:SUITE AG69
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-1146
Mailing Address - Country:US
Mailing Address - Phone:202-667-8701
Mailing Address - Fax:202-234-9218
Practice Address - Street 1:3636 16TH ST NW
Practice Address - Street 2:SUITE AG69
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-1146
Practice Address - Country:US
Practice Address - Phone:202-667-8701
Practice Address - Fax:202-234-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD11684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC025405900Medicaid
MD777791400Medicaid
MD777791400Medicaid