Provider Demographics
NPI:1821047556
Name:THEOBALD, MICHAEL ASHTON (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ASHTON
Last Name:THEOBALD
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 1:12042 6TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-4521
Mailing Address - Country:US
Mailing Address - Phone:206-361-8408
Mailing Address - Fax:
Practice Address - Street 1:21601 76TH AVE W
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7507
Practice Address - Country:US
Practice Address - Phone:425-640-4000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00011020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist