Provider Demographics
NPI:1811230147
Name:TOLLIVORO, THEODORE ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ANTHONY
Last Name:TOLLIVORO
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 1:1450 TREAT BLVD # 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-296-7340
Mailing Address - Fax:
Practice Address - Street 1:1479 YGNACIO VALLEY RD # 200
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2986
Practice Address - Country:US
Practice Address - Phone:925-296-7340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132935207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology