Provider Demographics
NPI:1366566416
Name:THEODORO, GRACE M (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:M
Last Name:THEODORO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GRACIELA
Other - Middle Name:H
Other - Last Name:THEODORO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9 LADUE ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8321
Mailing Address - Country:US
Mailing Address - Phone:314-432-1805
Mailing Address - Fax:
Practice Address - Street 1:4021 S 700 E STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2184
Practice Address - Country:US
Practice Address - Phone:314-432-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ307632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A28658Medicare UPIN