Healthcare Provider Details

I. General information

NPI: 1396778239
Provider Name (Legal Business Name): ROBERT JAMES THEOBALD III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14547 BRUCE B DOWNS BLVD SUITE B
TAMPA FL
33613-2709
US

IV. Provider business mailing address

38135 MARKET SQ
ZEPHYRHILLS FL
33542-7505
US

V. Phone/Fax

Practice location:
  • Phone: 813-875-2600
  • Fax: 813-875-2626
Mailing address:
  • Phone: 813-780-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberOS9540
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: