Provider Demographics
NPI:1063686624
Name:THEODOROU, WILLIAM WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WESLEY
Last Name:THEODOROU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WILLIAM
Other - Middle Name:WESLEY
Other - Last Name:POTTS
Other - Suffix:III
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-5495
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.0557402085R0202X
IL036.1306142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program