Provider Demographics
NPI:1134173537
Name:MICLAU, THEODORE III (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:MICLAU
Suffix:III
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 1:2550 23RD ST BLDG 9
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3504
Mailing Address - Country:US
Mailing Address - Phone:415-206-8812
Mailing Address - Fax:415-647-3733
Practice Address - Street 1:2550 23RD ST BLDG 9
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3504
Practice Address - Country:US
Practice Address - Phone:415-206-8812
Practice Address - Fax:415-647-3733
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81843207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G818430Medicaid
CA110150231OtherRAILROAD MEDICARE
F91139Medicare UPIN
CA00G818430Medicare ID - Type Unspecified