Healthcare Provider Details

I. General information

NPI: 1275538134
Provider Name (Legal Business Name): THEODORE P SKAARUP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 W 51ST AVE
KENNEWICK WA
99337-4626
US

IV. Provider business mailing address

PO BOX 1663
WALLA WALLA WA
99362-0031
US

V. Phone/Fax

Practice location:
  • Phone: 509-619-0562
  • Fax:
Mailing address:
  • Phone: 509-619-0562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD00037267
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: