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General NPI Number Information
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NPI Number | 1073518577
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Entity Type | Individual
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Provider Name | DAVID A THEODORO M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/20/2005
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Last Update Date | 08/27/2020
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Provider Practice Location Address
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Address Line | 12255 DE PAUL DR NORTH BLDG STE 260
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City | BRIDGETON
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State | MO
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Zip | 63044
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Country | US
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Telephone | 314-647-8269
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Fax | 314-646-1700
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Provider Business Mailing Address
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Address Line | PO BOX 23666
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City | JACKSON
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State | MS
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Zip | 39225-3666
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Country | US
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Telephone | 601-200-2780
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Fax | 601-200-2788
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 118293
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 036095641
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 28104
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License Number State | MS
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