Provider Demographics
NPI:1427158963
Name:GOLDEN, THEODORE ALFRED PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ALFRED PAUL
Last Name:GOLDEN
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 1:181 SHAGBARK DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1816
Mailing Address - Country:US
Mailing Address - Phone:248-626-2252
Mailing Address - Fax:
Practice Address - Street 1:181 SHAGBARK DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1816
Practice Address - Country:US
Practice Address - Phone:248-626-2252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028806207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1072873Medicaid
MI0705066991OtherBCBSM
MI0705066991OtherBCBSM
MI1072873Medicaid