Provider Demographics
NPI:1790084010
Name:JOHN, THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:JOHN
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 1:1221 SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3257
Mailing Address - Country:US
Mailing Address - Phone:989-779-5240
Mailing Address - Fax:989-779-5254
Practice Address - Street 1:726 4TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5656
Practice Address - Country:US
Practice Address - Phone:530-749-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA143051208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery