Provider Demographics
NPI:1730156217
Name:SOUTHGATE, THEODORE J (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:SOUTHGATE
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 1:201 LYONS AVE
Mailing Address - Street 2:SUITE G5
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2027
Mailing Address - Country:US
Mailing Address - Phone:973-926-7749
Mailing Address - Fax:973-923-4683
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:SUITE G5
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:973-926-7749
Practice Address - Fax:973-923-4683
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05005700207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7459106Medicaid
NJF51641Medicare UPIN
NJ7459106Medicaid