Provider Demographics
NPI:1609846658
Name:LEMLE, THEODORE L (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:L
Last Name:LEMLE
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 1:1901 REDROCK DR
Mailing Address - Street 2:PFS DEPT
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:1900 REDROCK DR
Practice Address - Street 2:REHOBOTH MCKINLEY CHRISTIAN HEALTH SERVICES
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5682
Practice Address - Country:US
Practice Address - Phone:505-863-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0621208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ249012Medicaid
NMNM009X31OtherBC/BS
AZ249012Medicaid