Provider Demographics
NPI:1699754697
Name:ROOSEVELT, THEODORE STEVEN (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:STEVEN
Last Name:ROOSEVELT
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 1:13909 W WAINWRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1969
Mailing Address - Country:US
Mailing Address - Phone:208-389-2213
Mailing Address - Fax:208-389-4659
Practice Address - Street 1:13909 W WAINWRIGHT DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1969
Practice Address - Country:US
Practice Address - Phone:208-389-2213
Practice Address - Fax:208-389-4659
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6142207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002712100Medicaid
1126993Medicare PIN
IDA45831Medicare UPIN