Provider Demographics
NPI:1578525606
Name:WIRECKI, THEODORE S (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:S
Last Name:WIRECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4770 E ILIFF AVE
Mailing Address - Street 2:#226
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-6061
Mailing Address - Country:US
Mailing Address - Phone:303-618-2303
Mailing Address - Fax:303-757-7994
Practice Address - Street 1:4770 E ILIFF AVE
Practice Address - Street 2:#226
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-6061
Practice Address - Country:US
Practice Address - Phone:303-618-2303
Practice Address - Fax:303-757-7994
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO208562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01208560Medicaid
COCO304566Medicare PIN
CO01208560Medicaid