Provider Demographics
NPI:1730304270
Name:THEODORE C.DOCU MD, PC
Entity type:Organization
Organization Name:THEODORE C.DOCU MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:COSTA
Authorized Official - Last Name:DOCU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-568-0553
Mailing Address - Street 1:506 FORT WASHINGTON AVE 1F
Mailing Address - Street 2:1F
Mailing Address - City:NEW YORK,NY
Mailing Address - State:NY
Mailing Address - Zip Code:10033
Mailing Address - Country:UM
Mailing Address - Phone:212-568-0553
Mailing Address - Fax:
Practice Address - Street 1:506 FORT WASHINGTON AVE 1F
Practice Address - Street 2:1F
Practice Address - City:NEW YORK,NY
Practice Address - State:NY
Practice Address - Zip Code:10033
Practice Address - Country:UM
Practice Address - Phone:212-568-0553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182886207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01189151Medicaid
NY01189151Medicaid