Healthcare Provider Details

I. General information

NPI: 1487889556
Provider Name (Legal Business Name): THEODORE GEORGIS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22924 CRENSHAW BLVD
TORRANCE CA
90505-3023
US

IV. Provider business mailing address

PO BOX 273
PALOS VERDES ESTATES CA
90274-0273
US

V. Phone/Fax

Practice location:
  • Phone: 310-530-4460
  • Fax: 310-530-4464
Mailing address:
  • Phone: 858-354-5606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberG49234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: