Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | D0014165 | MD |
NPI | 1306841614 |
---|---|
Provider Name | Roger Theodore |
First Address | Towson, MD 21286-3300 |
Second Address | Towson, MD 21286-3300 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2005 |
Last Update Date | 28/11/2016 |