Healthcare Provider Details

I. General information

NPI: 1902661671
Provider Name (Legal Business Name): THEO NERUDA STODDARD-BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 QUARRY RD
PALO ALTO CA
94304-1419
US

IV. Provider business mailing address

401 QUARRY RD
PALO ALTO CA
94304-1419
US

V. Phone/Fax

Practice location:
  • Phone: 650-498-9111
  • Fax:
Mailing address:
  • Phone: 650-498-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA207930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: