Provider Demographics
NPI:1104873611
Name:HOLE, THEODORE WILSON (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:WILSON
Last Name:HOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 LOMA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2915
Mailing Address - Country:US
Mailing Address - Phone:805-643-9975
Mailing Address - Fax:
Practice Address - Street 1:2937 LOMA VISTA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2915
Practice Address - Country:US
Practice Address - Phone:805-643-9975
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46762Medicare UPIN