Provider Demographics
NPI:1952477572
Name:FOLKERTH, THEODORE LEON (MD)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:LEON
Last Name:FOLKERTH
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:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:619-543-6164
Mailing Address - Fax:
Practice Address - Street 1:3998 VISTA WAY
Practice Address - Street 2:SUITE A
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4515
Practice Address - Country:US
Practice Address - Phone:760-726-2500
Practice Address - Fax:760-726-3279
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30651208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C306510Medicaid
CAWC30651EMedicare PIN
CA00C306510Medicaid