Healthcare Provider Details

I. General information

NPI: 1205863990
Provider Name (Legal Business Name): JAMES WILLIAM THEEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BLACK OAK DR
MEDFORD OR
97504-8447
US

IV. Provider business mailing address

3625 OLD CHERRY LN
MEDFORD OR
97504-9476
US

V. Phone/Fax

Practice location:
  • Phone: 541-734-3430
  • Fax: 541-734-3638
Mailing address:
  • Phone: 541-734-3430
  • Fax: 541-734-3638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD16267
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: