Provider Demographics
NPI:1710972021
Name:STRANGE, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:STRANGE
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 1:68 SEGUINE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3723
Mailing Address - Country:US
Mailing Address - Phone:718-356-6500
Mailing Address - Fax:
Practice Address - Street 1:68 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3723
Practice Address - Country:US
Practice Address - Phone:718-356-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA64647Medicare UPIN
NYA64647Medicare UPIN