Provider Demographics
NPI:1831714278
Name:TEODORO, ROJIN EDWARD CALLO (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ROJIN EDWARD
Middle Name:CALLO
Last Name:TEODORO
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8291 MARIAN ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2766
Mailing Address - Country:US
Mailing Address - Phone:586-960-4029
Mailing Address - Fax:
Practice Address - Street 1:18312 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-5007
Practice Address - Country:US
Practice Address - Phone:248-680-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant