Provider Demographics
NPI:1619081387
Name:PERRY, THEODORE G (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:G
Last Name:PERRY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3745 11TH CIR STE 101
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4838
Mailing Address - Country:US
Mailing Address - Phone:772-589-0580
Mailing Address - Fax:
Practice Address - Street 1:3745 11TH CIR STE 101
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4838
Practice Address - Country:US
Practice Address - Phone:772-589-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58748208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23154OtherBCBS#
FL122482900Medicaid
FL43644OtherUNITED HEALTHCARE#
FL020037078OtherRAIL ROAD MEDICARE
FL373707100Medicaid
FL020037078OtherRAIL ROAD MEDICARE