Provider Demographics
NPI:1568432912
Name:VASILOPOULOS, SOTIRIOS A (MD)
Entity Type:Individual
Prefix:
First Name:SOTIRIOS
Middle Name:A
Last Name:VASILOPOULOS
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-389-2338
Mailing Address - Fax:414-385-8987
Practice Address - Street 1:5900 S LAKE DR
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-3171
Practice Address - Country:US
Practice Address - Phone:414-489-4190
Practice Address - Fax:414-489-4015
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD439059207RG0100X
WI70814207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024199370001Medicaid
PA2152337OtherBLUE CROSS/BLUE SHIELD
PAPENDINGOtherRAILROAD MEDICARE
PA1024199370001Medicaid
PAPENDINGMedicare PIN