Provider Demographics
NPI:1982611745
Name:THEODOROFF, CHRISTOPHER DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:THEODOROFF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61656 SPRING CIRCLE TRL
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48094-1143
Mailing Address - Country:US
Mailing Address - Phone:248-656-3292
Mailing Address - Fax:
Practice Address - Street 1:28825 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4128
Practice Address - Country:US
Practice Address - Phone:586-573-0470
Practice Address - Fax:586-573-0648
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003333152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2674552Medicaid
MI5189678Medicaid
MI1314720001OtherNSC
MI900E066750OtherBCBS
MI5189669Medicaid
MI2674552Medicaid
U25916Medicare UPIN
MI5189678Medicaid
MIP39630001Medicare ID - Type Unspecified
MIP41880006Medicare ID - Type Unspecified
MIP41870006Medicare ID - Type Unspecified