Provider Demographics
NPI:1558707588
Name:THEO MEDICAL DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:THEO MEDICAL DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:
Authorized Official - Last Name:THEODOSATOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO, MPH
Authorized Official - Phone:407-671-3634
Mailing Address - Street 1:652 SAINT JOHNS CT
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4917
Mailing Address - Country:US
Mailing Address - Phone:407-671-3634
Mailing Address - Fax:
Practice Address - Street 1:652 SAINT JOHNS CT
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4917
Practice Address - Country:US
Practice Address - Phone:407-671-3634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS38457207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001101800Medicaid