Provider Demographics
NPI:1003880774
Name:HAILU, THEODOROS (MD)
Entity Type:Individual
Prefix:
First Name:THEODOROS
Middle Name:
Last Name:HAILU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 863481
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3481
Mailing Address - Country:US
Mailing Address - Phone:800-514-1494
Mailing Address - Fax:
Practice Address - Street 1:5000 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-1503
Practice Address - Country:US
Practice Address - Phone:954-730-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0089942207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270988100Medicaid
FL50653OtherBCBS
FLP00290620OtherRR MCR
FL270988100Medicaid
FL50653BMedicare PIN
FL$$$$$$$$$OtherTRICARE
FL50653CMedicare ID - Type UnspecifiedMEDICARE
FLP00290620OtherRR MCR