Provider Demographics
NPI:1679743330
Name:MARIAM, THEODROS (PA)
Entity type:Individual
Prefix:MR
First Name:THEODROS
Middle Name:
Last Name:MARIAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-6212
Mailing Address - Country:US
Mailing Address - Phone:215-855-9418
Mailing Address - Fax:
Practice Address - Street 1:1033 W GERMANTOWN PIKE
Practice Address - Street 2:VALLEY FORGE MEDICAL CENTER & HOSPITAL
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19403-3905
Practice Address - Country:US
Practice Address - Phone:610-539-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-09
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053056363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical