Healthcare Provider Details

I. General information

NPI: 1528628963
Provider Name (Legal Business Name): PATCHOUCO THEODORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 ALCOA HWY # U-67
KNOXVILLE TN
37920-1511
US

IV. Provider business mailing address

10300 SW 216TH ST
CUTLER BAY FL
33190-1003
US

V. Phone/Fax

Practice location:
  • Phone: 865-305-9350
  • Fax: 865-305-8942
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number66626
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number350083
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: