Provider Demographics
NPI:1528138294
Name:HENDRIX, THEODRIC BLUE JR (MD)
Entity type:Individual
Prefix:DR
First Name:THEODRIC
Middle Name:BLUE
Last Name:HENDRIX
Suffix:JR
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 1:450 N ROXBURY DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4231
Mailing Address - Country:US
Mailing Address - Phone:310-652-3570
Mailing Address - Fax:310-388-0157
Practice Address - Street 1:450 N ROXBURY DR
Practice Address - Street 2:SUITE 500
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4231
Practice Address - Country:US
Practice Address - Phone:310-652-3570
Practice Address - Fax:310-388-0157
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29978174400000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A299780OtherBLUE SHIELD PROVIDER #
CA00A299780OtherBLUE SHIELD PROVIDER #