Healthcare Provider Details

I. General information

NPI: 1538384003
Provider Name (Legal Business Name): THEODORE JAMES FALLON JR. M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 KING OF PRUSSIA RD
WAYNE PA
19087-2830
US

IV. Provider business mailing address

PO BOX 81
CHESTER SPRINGS PA
19425-0081
US

V. Phone/Fax

Practice location:
  • Phone: 610-827-7436
  • Fax: 610-827-7436
Mailing address:
  • Phone: 610-827-7436
  • Fax: 610-827-0962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD028700E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD028700E
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD028700E
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberMD028700E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: