Provider Demographics
NPI:1700379740
Name:ZEMANUEL, THEODROS M (DO)
Entity Type:Individual
Prefix:
First Name:THEODROS
Middle Name:M
Last Name:ZEMANUEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11807 SOUTH FWY STE 363
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7045
Mailing Address - Country:US
Mailing Address - Phone:817-806-1143
Mailing Address - Fax:817-806-1144
Practice Address - Street 1:11807 SOUTH FWY STE 363
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7045
Practice Address - Country:US
Practice Address - Phone:817-806-1143
Practice Address - Fax:817-806-1144
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT5709207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8SM603OtherBCBS
TX1700379740Medicaid