Provider Demographics
NPI:1740379528
Name:POELKING, THEODORE J (DC)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
Last Name:POELKING
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8648 CYPRESS TRL
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-8361
Mailing Address - Country:US
Mailing Address - Phone:937-885-6110
Mailing Address - Fax:
Practice Address - Street 1:2660 WOODMAN CENTER CT
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1477
Practice Address - Country:US
Practice Address - Phone:937-299-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2199111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPO9280591OtherMEDICARE GROUP
OH0128301Medicaid
OHU55072Medicare UPIN
OHPO0779192Medicare PIN