Provider Demographics
NPI:1750422184
Name:THEILADE, KAREN CHRISTIANE (MD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:CHRISTIANE
Last Name:THEILADE
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 1:120 CYPRESS EDGE DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-8453
Mailing Address - Country:US
Mailing Address - Phone:386-586-4410
Mailing Address - Fax:386-445-3398
Practice Address - Street 1:120 CYPRESS EDGE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8453
Practice Address - Country:US
Practice Address - Phone:386-586-4410
Practice Address - Fax:386-445-3398
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106807207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14AA4OtherBCBS
FL003120001Medicaid
FLP01170719OtherRAILROAD
FL14AA4OtherBCBS