Healthcare Provider Details

I. General information

NPI: 1205520749
Provider Name (Legal Business Name): THEODORE HENRY KATZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65212-1453
US

IV. Provider business mailing address

4311 KENTSFIELD LN APT 102
COLUMBIA MO
65201-3644
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4141
  • Fax:
Mailing address:
  • Phone: 515-664-7047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberR-12839
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2024025516
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: