Provider Demographics
NPI:1811917735
Name:THEOS, AMY (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:THEOS
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 1:30 N 1900 E # 4A330
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:801-581-2955
Mailing Address - Fax:
Practice Address - Street 1:81 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1125
Practice Address - Country:US
Practice Address - Phone:801-581-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13183449-1205207NP0225X
AL21555208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL070014725OtherRAILROAD MEDICARE
AL000096171OtherBLUE CROSS
AL000096173Medicaid
AL009935631Medicaid
AL009999625Medicaid
AL051533057OtherBLUE CROSS
ALH15937OtherHEALTHSPRING OF ALABAMA
AL051528663OtherBLUE CROSS
AL000096171Medicaid
AL009935598Medicaid
AL96171OtherBLUE CROSS
ALH15937OtherVIVA
AL96171OtherBLUE CROSS
AL051533057OtherBLUE CROSS