Provider Demographics
NPI:1295896041
Name:STAAHL, THEODORE EDMUND (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:EDMUND
Last Name:STAAHL
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 1:1329 SPANOS CT STE A-1
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2806
Mailing Address - Country:US
Mailing Address - Phone:209-577-5700
Mailing Address - Fax:209-577-5968
Practice Address - Street 1:1329 SPANOS CT STE A-1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2806
Practice Address - Country:US
Practice Address - Phone:209-577-5700
Practice Address - Fax:209-577-5968
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG037452174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA47096Medicare UPIN