Healthcare Provider Details

I. General information

NPI: 1518926161
Provider Name (Legal Business Name): THEODORE TOWLES LLANSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FRIEDBERG HEALTH CLINIC CMR 453
APO AE
09074
DE

IV. Provider business mailing address

AATN: CREDENTIALS OFFICE CMR 442
APO AE
09042
DE

V. Phone/Fax

Practice location:
  • Phone: 49060310183204
  • Fax:
Mailing address:
  • Phone: 496221172274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01055363A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: