Provider Demographics
NPI:1386609881
Name:WALLER, THEODORE (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:WALLER
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 1:237 WILLIAM HOWARD TAFT RD
Mailing Address - Street 2:2ND FLOOR, CBO 2-3
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2610
Mailing Address - Country:US
Mailing Address - Phone:513-792-7800
Mailing Address - Fax:513-792-7807
Practice Address - Street 1:11140 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2309
Practice Address - Country:US
Practice Address - Phone:513-792-7800
Practice Address - Fax:513-792-7807
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046812207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000238182OtherANTHEM MIDDLETOWN
KY64860562Medicaid
OH0549464Medicaid
2520401OtherUNITED
0642403OtherAETNA
IN100335970Medicaid
000000019745OtherANTHEM
2520401OtherUNITED
OH0549464Medicaid
OHWA4246301Medicare PIN
000000238182OtherANTHEM MIDDLETOWN
OH0842182Medicare PIN