Provider Demographics
NPI:1750776225
Name:DRIVAS, THEODORE GEORGE (MD, PHD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:GEORGE
Last Name:DRIVAS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:STE 3005
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-662-4740
Mailing Address - Fax:215-614-0298
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:STE 3005
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-662-4740
Practice Address - Fax:215-614-0298
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD467163207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)