Provider Demographics
NPI:1457384406
Name:THEUS, EMMANUELLA (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUELLA
Middle Name:
Last Name:THEUS
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 1:7200 CORPORATE CENTER DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-1200
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:305-500-2080
Practice Address - Street 1:1240 NW 119TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33167-3232
Practice Address - Country:US
Practice Address - Phone:305-685-5688
Practice Address - Fax:305-688-7995
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME057382208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051295800Medicaid
FL051295800Medicaid
FL108602Medicare ID - Type Unspecified