Provider Demographics
NPI:1730144635
Name:JELLINEK, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:JELLINEK
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 905
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02541
Mailing Address - Country:US
Mailing Address - Phone:508-548-8989
Mailing Address - Fax:508-548-5789
Practice Address - Street 1:449 ROUTE 130
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:MA
Practice Address - Zip Code:02563
Practice Address - Country:US
Practice Address - Phone:508-888-9241
Practice Address - Fax:508-888-9243
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA297122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
100754OtherMAGELLAN
703893OtherTUFTS
100754OtherMAGELLAN
MAC04502Medicare ID - Type Unspecified