Provider Demographics
NPI:1194707950
Name:SNIDER, THEODORE (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:SNIDER
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:PO BOX 681149
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78268-1149
Mailing Address - Country:US
Mailing Address - Phone:210-558-6288
Mailing Address - Fax:210-558-6289
Practice Address - Street 1:4085 DE ZAVALA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SHAVANO PARK
Practice Address - State:TX
Practice Address - Zip Code:78249-2084
Practice Address - Country:US
Practice Address - Phone:210-558-6288
Practice Address - Fax:210-558-6289
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8418207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103547905Medicaid
TX8K2623Medicare PIN
TX103547905Medicaid