Provider Demographics
NPI:1609962000
Name:NASSAR, THEODORE R (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:R
Last Name:NASSAR
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 1:363 E ALMOND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-5753
Mailing Address - Country:US
Mailing Address - Phone:559-674-0917
Mailing Address - Fax:559-674-3104
Practice Address - Street 1:363 E ALMOND AVE STE 101
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5753
Practice Address - Country:US
Practice Address - Phone:559-674-0917
Practice Address - Fax:559-674-3104
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31164207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100790Medicaid
CA00A31140Medicare ID - Type Unspecified
CAGR0100790Medicaid