Provider Demographics
NPI:1487661401
Name:PANTELOGLOU, THEODORA (DO)
Entity Type:Individual
Prefix:
First Name:THEODORA
Middle Name:
Last Name:PANTELOGLOU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ORCHARD PL
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-5003
Mailing Address - Country:US
Mailing Address - Phone:516-285-8219
Mailing Address - Fax:
Practice Address - Street 1:21430 46TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3316
Practice Address - Country:US
Practice Address - Phone:718-229-1064
Practice Address - Fax:718-423-2924
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics