Provider Demographics
NPI:1023097201
Name:PACHECO, THEODORE RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:RAYMOND
Last Name:PACHECO
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 1:3600 KOLBE RD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1654
Mailing Address - Country:US
Mailing Address - Phone:440-414-9200
Mailing Address - Fax:216-201-5582
Practice Address - Street 1:3600 KOLBE RD
Practice Address - Street 2:SUITE 127
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1654
Practice Address - Country:US
Practice Address - Phone:440-414-9200
Practice Address - Fax:216-201-5582
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065306207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341221800068OtherCARESOURCE
OH000000128727OtherANTHEM
OHE65306OtherSUMMACARE
OH0972863Medicaid
OH100399OtherKAISER
060023253OtherRAILROAD MEDICARE
OH100399OtherKAISER
OH9288884Medicare UPIN
OH341221800068OtherCARESOURCE
OH4011483Medicare PIN