Provider Demographics
NPI:1194201475
Name:THEOBALD, HEATHER ANN (DO)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:THEOBALD
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2910 N 3RD AVE # 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4434
Mailing Address - Country:US
Mailing Address - Phone:602-406-3181
Mailing Address - Fax:022-642-4176
Practice Address - Street 1:33300 N 32ND AVE STE 310
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-8826
Practice Address - Country:US
Practice Address - Phone:623-562-3730
Practice Address - Fax:022-948-2746
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ009525208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ150612Medicaid