Provider Demographics
NPI:1255702569
Name:MACARIO, THEODORE
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:MACARIO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:THEODORE
Other - Middle Name:
Other - Last Name:MACARIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:370 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-3050
Practice Address - Fax:718-334-3015
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical