Provider Demographics
NPI:1194733436
Name:PRENTICE, THEODORE C (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:C
Last Name:PRENTICE
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 1:11525 BROOKSHIRE AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4982
Mailing Address - Country:US
Mailing Address - Phone:562-861-1988
Mailing Address - Fax:562-861-5835
Practice Address - Street 1:11525 BROOKSHIRE AVE STE 205
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4982
Practice Address - Country:US
Practice Address - Phone:562-861-1988
Practice Address - Fax:562-861-5835
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWG38015M2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066640Medicaid
CAWG38015MOtherLICENSE
CAGR0066640Medicaid