Provider Demographics
NPI:1588641013
Name:STAHL, THEODORE J (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:STAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:579A CRANBURY RD
Mailing Address - Street 2:UNIVERSITY RADIOLOGY GROUP PC
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816
Mailing Address - Country:US
Mailing Address - Phone:732-390-0040
Mailing Address - Fax:732-390-1856
Practice Address - Street 1:579A CRANBURY RD
Practice Address - Street 2:UNIVERSITY RADIOLOGY GROUP PC
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816
Practice Address - Country:US
Practice Address - Phone:732-390-0040
Practice Address - Fax:732-390-1856
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA016832002085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1119508Medicaid
NJ1119508Medicaid
NJ400574Medicare PIN