Provider Demographics
NPI:1609842210
Name:THEOBALD, MARTIN J (OD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:THEOBALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4000
Mailing Address - Country:US
Mailing Address - Phone:218-727-6400
Mailing Address - Fax:
Practice Address - Street 1:3308 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4000
Practice Address - Country:US
Practice Address - Phone:218-727-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2549152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA62871023475OtherPREFERRED ONE
MN110960OtherUCARE
MN2207594OtherMEDICA
MN6C248THOtherFIRST PLAN MINNESOTA
MN897821023475OtherPREFERRED ONE
MN6C248THOtherATRIUM & BCBS
MN2203074OtherMEDICA
MN6C248THOtherATRIUM & BCBS