Provider Demographics
NPI:1619081387
Name:PERRY, THEODORE G (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:G
Last Name:PERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:920 37TH PL
Mailing Address - Street 2:STE. 104
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6573
Mailing Address - Country:US
Mailing Address - Phone:772-562-9899
Mailing Address - Fax:772-562-6237
Practice Address - Street 1:920 37TH PL
Practice Address - Street 2:STE. 104
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6573
Practice Address - Country:US
Practice Address - Phone:772-562-9899
Practice Address - Fax:772-562-6237
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0058748208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23154OtherBCBS#
FL373707100Medicaid
FL43644OtherUNITED HEALTHCARE#
FL020037078OtherRAIL ROAD MEDICARE
FL373707100Medicaid
FL020037078OtherRAIL ROAD MEDICARE