Provider Demographics
NPI:1326439241
Name:CHIN-THEODOROU, JAMIE (MD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:CHIN-THEODOROU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 VILLAGE PT STE 102
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9695
Mailing Address - Country:US
Mailing Address - Phone:219-395-1046
Mailing Address - Fax:219-395-1570
Practice Address - Street 1:3100 VILLAGE PT STE 102
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9695
Practice Address - Country:US
Practice Address - Phone:219-395-1046
Practice Address - Fax:219-395-1570
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.068540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine