Provider Demographics
NPI:1669537395
Name:SECTISH, THEODORE CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:CHARLES
Last Name:SECTISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHERTON
Mailing Address - State:CA
Mailing Address - Zip Code:94027-3815
Mailing Address - Country:US
Mailing Address - Phone:650-326-9115
Mailing Address - Fax:650-497-8228
Practice Address - Street 1:725 WELCH RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1601
Practice Address - Country:US
Practice Address - Phone:650-497-8979
Practice Address - Fax:650-497-8228
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41804208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48700Medicare UPIN