Provider Demographics
NPI:1659518983
Name:ROMAN, THEODORE P (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:P
Last Name:ROMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-1012
Mailing Address - Country:US
Mailing Address - Phone:605-964-3007
Mailing Address - Fax:605-964-1139
Practice Address - Street 1:317 MAIN STREET
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-964-3007
Practice Address - Fax:605-964-1139
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0527OtherSD PHYSICIAN LICENSE