Provider Demographics
NPI:1770566382
Name:THEODORAN, CHRIS G (DO)
Entity type:Individual
Prefix:
First Name:CHRIS
Middle Name:G
Last Name:THEODORAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3200
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17604-3200
Mailing Address - Country:US
Mailing Address - Phone:717-393-1771
Mailing Address - Fax:717-393-2782
Practice Address - Street 1:2106 HARRISBURG PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2644
Practice Address - Country:US
Practice Address - Phone:717-393-1771
Practice Address - Fax:717-393-2782
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS005449L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001090835/0002Medicaid
PAB40915Medicare UPIN
PA188110FUKMedicare ID - Type Unspecified