Basic Information
| Provider Information | |||||||||
| NPI: | 1609813799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHOMA | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843966 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641843966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738843300 | ||||||||
| FaxNumber: | 5738840943 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652120001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738822663 | ||||||||
| FaxNumber: | 5738825847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2006006302 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | 2006006302 | MO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 204960 | 01 | MO | BLUE SHIELD | OTHER | 739111 | 01 | MO | HEALTHLINK | OTHER | 200757409 | 05 | MO | MEDICAID | 204960 | 01 | MO | BLUE CHOICE | OTHER |