Provider Demographics
NPI:1356773006
Name:ZOMBOLAS, THEODORE (PHD, LAC)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:ZOMBOLAS
Suffix:
Gender:M
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 INMAN TER
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3614
Mailing Address - Country:US
Mailing Address - Phone:215-962-0155
Mailing Address - Fax:
Practice Address - Street 1:234 MILL ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-4809
Practice Address - Country:US
Practice Address - Phone:215-692-0155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAKO000526171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist