Provider Demographics
NPI:1215798939
Name:USO, THEOPHILUS DOUGLAS
Entity type:Individual
Prefix:
First Name:THEOPHILUS
Middle Name:DOUGLAS
Last Name:USO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 HARRISON ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-4700
Mailing Address - Country:US
Mailing Address - Phone:510-496-4655
Mailing Address - Fax:
Practice Address - Street 1:4917 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-2920
Practice Address - Country:US
Practice Address - Phone:510-496-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00257357343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)