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NPI Code Detail

MEDICARE: DALE E. THEOBALD M.D., PH.D.

MEDICARE: DALE E. THEOBALD M.D., PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084P0802XAddiction Psychiatry Physician200110234AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1000000538641OTHERINANTHEM
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1053383083
Entity Type Code : Individual
Provider Name (Legal Business Name) : DALE E. THEOBALD M.D., PH.D.
Provider Business Mailing Address
First Line : 6626 E 75TH ST
Second Line : SUITE 500
City : INDIANAPOLIS
State : IN
Zip : 46250-2805
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 7229 CLEARVISTA DR
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46256-1698
Country : US
Telephone Number : 317-621-4341
Fax Number : 317-621-4366
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/03/2006
Last Update Date : 11/27/2023

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