Provider Demographics
NPI:1639274228
Name:KEPROS, THEODORE JOHN (PT)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOHN
Last Name:KEPROS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-1465
Mailing Address - Country:US
Mailing Address - Phone:319-895-4085
Mailing Address - Fax:319-895-8013
Practice Address - Street 1:108 1ST ST SE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1465
Practice Address - Country:US
Practice Address - Phone:319-895-4085
Practice Address - Fax:319-895-8013
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA023362251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665430Medicaid
IAIB1213Medicare PIN
IAIB1213023Medicare PIN
IAI19172Medicare PIN
IAI19172050Medicare PIN
IAIB1212Medicare PIN
IA166543Medicare ID - Type Unspecified
IAIB1212023Medicare PIN