Provider Demographics
NPI:1639171101
Name:THEODORE, GEORGE H (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:H
Last Name:THEODORE
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:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-0086
Mailing Address - Country:US
Mailing Address - Phone:781-749-9071
Mailing Address - Fax:781-749-2133
Practice Address - Street 1:175 CAMBRIDGE ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2743
Practice Address - Country:US
Practice Address - Phone:617-724-7009
Practice Address - Fax:617-643-1006
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150940207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3152502Medicaid
MAA21271Medicare ID - Type Unspecified
MAG26707Medicare UPIN