Provider Demographics
NPI:1396781233
Name:THEOBALD, CARYN (MD)
Entity type:Individual
Prefix:
First Name:CARYN
Middle Name:
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1681
Mailing Address - Country:US
Mailing Address - Phone:419-636-4517
Mailing Address - Fax:419-636-6438
Practice Address - Street 1:3926 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1712
Practice Address - Country:US
Practice Address - Phone:419-445-2015
Practice Address - Fax:419-445-8102
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-082516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00245754OtherRAILROAD
OH2432264Medicaid
OH4111972Medicare PIN