Provider Demographics
NPI:1750308581
Name:CWYNAR, THEODORE MARK (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:MARK
Last Name:CWYNAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:T.
Other - Middle Name:MARK
Other - Last Name:CWYNAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:7555 E OSBORN RD
Practice Address - Street 2:STE 201
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6442
Practice Address - Country:US
Practice Address - Phone:480-949-7080
Practice Address - Fax:480-675-9145
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0349130OtherBLUE CROSS BLUE SHIELD
AZ251059-01Medicaid
AZMD10871Medicare PIN
AZC99322Medicare UPIN