Healthcare Provider Details

I. General information

NPI: 1962643478
Provider Name (Legal Business Name): THEOPHILE BARLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ESSIE DAVISON DR
CLARINDA IA
51632-2915
US

IV. Provider business mailing address

PO BOX 217 220 ESSIE DAVISON DR.,
CLARINDA IA
51632-2915
US

V. Phone/Fax

Practice location:
  • Phone: 712-542-2176
  • Fax: 712-542-8397
Mailing address:
  • Phone: 712-542-2176
  • Fax: 712-542-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL.3021R
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38630
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: