Provider Demographics
NPI:1588658702
Name:THEIS, WARREN STUART (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:STUART
Last Name:THEIS
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 1:1405 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4528
Mailing Address - Country:US
Mailing Address - Phone:912-285-8822
Mailing Address - Fax:912-285-8898
Practice Address - Street 1:1405 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4528
Practice Address - Country:US
Practice Address - Phone:912-285-8822
Practice Address - Fax:912-285-8898
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055345208D00000X
VA0101237160208D00000X
CAA84102208D00000X
FLME96329208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67269005AMedicaid
GA08BBRLRMedicare PIN
GA67269005AMedicaid