Provider Demographics
NPI:1396102687
Name:PHELPS, THEODORE
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:PHELPS
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 1:169 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WHITELAND
Mailing Address - State:IN
Mailing Address - Zip Code:46184-1738
Mailing Address - Country:US
Mailing Address - Phone:317-626-9335
Mailing Address - Fax:
Practice Address - Street 1:169 WEST ST
Practice Address - Street 2:
Practice Address - City:WHITELAND
Practice Address - State:IN
Practice Address - Zip Code:46184-1738
Practice Address - Country:US
Practice Address - Phone:317-626-9335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician