Provider Demographics
NPI:1528079795
Name:KIRKLAND, THEO NEAL III (MD)
Entity type:Individual
Prefix:
First Name:THEO
Middle Name:NEAL
Last Name:KIRKLAND
Suffix:III
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 1:5709 WAVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7336
Mailing Address - Country:US
Mailing Address - Phone:858-752-7989
Mailing Address - Fax:858-459-7171
Practice Address - Street 1:5709 WAVERLY AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7336
Practice Address - Country:US
Practice Address - Phone:858-752-7989
Practice Address - Fax:858-459-7471
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39331207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G393310Medicaid
A89684Medicare UPIN
CA00G393310Medicaid