Provider Demographics
NPI:1598765760
Name:FOTOPOULOS, THEODORE N (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:N
Last Name:FOTOPOULOS
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 1:5534 GULF DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-4000
Mailing Address - Country:US
Mailing Address - Phone:727-847-3992
Mailing Address - Fax:727-848-1118
Practice Address - Street 1:5534 GULF DR
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4000
Practice Address - Country:US
Practice Address - Phone:727-847-3992
Practice Address - Fax:727-848-1118
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063090207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL591798817OtherHUMANA
FL08190OtherWELLCARE
FL31796OtherBLUE CROSS BLUE SHIELD
FL070009211OtherRAILROAD MEDICARE
FL242931OtherAVMED
FL2017793OtherAETNA
FL8550571-003OtherCIGNA
FL242931OtherAVMED
FL070009211OtherRAILROAD MEDICARE
FL8550571-003OtherCIGNA
FL08190OtherWELLCARE
FL250284400Medicaid