Provider Demographics
NPI:1760464721
Name:GAYLOR, THEODORE H (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:H
Last Name:GAYLOR
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 1:1251 S CEDAR CREST BLVD
Mailing Address - Street 2:#110
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6205
Mailing Address - Country:US
Mailing Address - Phone:610-770-9797
Mailing Address - Fax:610-770-9521
Practice Address - Street 1:1251 S CEDAR CREST BLVD
Practice Address - Street 2:#110
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6205
Practice Address - Country:US
Practice Address - Phone:610-770-9797
Practice Address - Fax:610-770-9521
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022099E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02348200OtherCAPITAL BLUE CROSS
PA0549870OtherAETNA US HEALTHCARE
PA00640920Medicaid
PAB35505Medicare UPIN
PA702697Medicare ID - Type Unspecified