Healthcare Provider Details

I. General information

NPI: 1710929963
Provider Name (Legal Business Name): THEODORE L. PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 E ELVIRA RD
TUCSON AZ
85756-7124
US

IV. Provider business mailing address

1635 DIVISADERO STREET SUITE 625, BOX 1821
SAN FRANCISCO CA
94143-0001
US

V. Phone/Fax

Practice location:
  • Phone: 520-874-4024
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA19551
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA19551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: