Provider Demographics
NPI:1598845786
Name:VROUSTOURIS, THEODORA (OOD)
Entity Type:Individual
Prefix:DR
First Name:THEODORA
Middle Name:
Last Name:VROUSTOURIS
Suffix:
Gender:F
Credentials:OOD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7263E ARLINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3219
Mailing Address - Country:US
Mailing Address - Phone:703-573-1200
Mailing Address - Fax:703-573-1250
Practice Address - Street 1:7263E ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3219
Practice Address - Country:US
Practice Address - Phone:703-573-1200
Practice Address - Fax:703-573-1250
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618 000576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA286010OtherANTHEM-CC
VA9231676Medicaid
VA286011OtherANTHEM-LP
VA277700OtherALLIANCE,MDIPA,MAMSI,OPC
VA9314-0006OtherBCBS-CAREFIRST
VA2119694OtherAETNA-HMO
VA5675449OtherAETNA-PPO
VA5675449OtherAETNA-PPO
VA004608N11Medicare ID - Type UnspecifiedMEDICARE