Provider Demographics
NPI:1780722595
Name:THEO L MEYER III PEDIATRICS CHARTERED
Entity type:Organization
Organization Name:THEO L MEYER III PEDIATRICS CHARTERED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEO
Authorized Official - Middle Name:L
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-365-5898
Mailing Address - Street 1:1666 MOUND STREET
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236
Mailing Address - Country:US
Mailing Address - Phone:941-365-5898
Mailing Address - Fax:941-366-5827
Practice Address - Street 1:1666 MOUND STREET
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236
Practice Address - Country:US
Practice Address - Phone:941-365-5898
Practice Address - Fax:941-366-5827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 43654208000000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251685300Medicaid