Provider Demographics
NPI:1669170114
Name:STOVALL, THEODORE ROGER
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:ROGER
Last Name:STOVALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 CONDESA DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-5241
Mailing Address - Country:US
Mailing Address - Phone:916-208-1950
Mailing Address - Fax:
Practice Address - Street 1:9229 CONDESA DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-5241
Practice Address - Country:US
Practice Address - Phone:916-208-1950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist