Basic Information
| Provider Information | |||||||||
| NPI: | 1811230147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLLIVORO | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 TREAT BLVD # 300 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945972168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252967340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1479 YGNACIO VALLEY RD # 200 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252967340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2013 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | A132935 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.