Provider Demographics
NPI:1548596422
Name:CARNER, THEODORE CLYDE (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:CLYDE
Last Name:CARNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 N. 32ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:602-971-0950
Mailing Address - Fax:
Practice Address - Street 1:12251 N 32ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:602-971-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20564207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery