Provider Demographics
NPI:1336254515
Name:DERSE, THEODORE SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:SCOTT
Last Name:DERSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:T
Other - Middle Name:SCOTT
Other - Last Name:DERSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:877-498-4490
Mailing Address - Fax:
Practice Address - Street 1:1260 N ARENDELL AVE
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-8730
Practice Address - Country:US
Practice Address - Phone:919-235-1965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34915207Q00000X
IL036139601207Q00000X
NC2022-01023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34175800Medicaid
IL036139601Medicaid
BD6223894OtherDEA NUMBER
IL036139601Medicaid