Provider Demographics
NPI:1427072248
Name:SHERMAN, THEODORE ROOSEVELT (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:ROOSEVELT
Last Name:SHERMAN
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 1:1201 5TH AVE N
Mailing Address - Street 2:SUITE 410
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1433
Mailing Address - Country:US
Mailing Address - Phone:727-822-5410
Mailing Address - Fax:941-746-4111
Practice Address - Street 1:1201 5TH AVE N
Practice Address - Street 2:SUITE 410
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1433
Practice Address - Country:US
Practice Address - Phone:727-822-5410
Practice Address - Fax:941-746-4111
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379926300Medicaid
E52992Medicare UPIN
FL379926300Medicaid