
First Name
Ted Mueller
Last Name
Doe
Date of Birth
1961-09-22
Gender
Other
Phone Number
(948) 730-4755
Insurance Provider
Herzog, Krajcik and Schaefer
Patient ID
14594
Emergency Contact
Jane Doe (+1 987 654 3210)
Street Address
123 Main St, Apt 4B
City
Denver
State/Province
Colorado
Zip Code
80202
Country
United States
Emergency Contact Address
456 Elm St, Apt 10C, Denver, CO