Provider Demographics
NPI:1881674703
Name:SAUER, THEODORE STEPHEN JR (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:STEPHEN
Last Name:SAUER
Suffix:JR
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 1:2622 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5410
Mailing Address - Country:US
Mailing Address - Phone:260-425-3100
Mailing Address - Fax:260-745-1321
Practice Address - Street 1:2622 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5410
Practice Address - Country:US
Practice Address - Phone:260-425-3100
Practice Address - Fax:260-745-1321
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084790207Q00000X
IN01059997A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000375796OtherANTHEM
IN200529220Medicaid
IN200529220Medicaid
IN940670UUUMedicare PIN