Basic Information
| Provider Information | |||||||||
| NPI: | 1659379147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | ELIAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3198 GRAND CONCOURSE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104581000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186180401 | ||||||||
| FaxNumber: | 7187954394 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 GRAND CONCOURSE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104534303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182997295 | ||||||||
| FaxNumber: | 7182996797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 06/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 129095 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00238188 | 05 | NY | MEDICAID |