Provider Demographics
NPI:1619970225
Name:THEODOROPOULOS, BOZENA GRAZYNA (MD)
Entity Type:Individual
Prefix:
First Name:BOZENA
Middle Name:GRAZYNA
Last Name:THEODOROPOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BOZENA
Other - Middle Name:GRAZYNA
Other - Last Name:MULVENNA (SZNAJDER)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2050 CLAIRE CT
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-7635
Mailing Address - Country:US
Mailing Address - Phone:844-656-8763
Mailing Address - Fax:847-556-1715
Practice Address - Street 1:2050 CLAIRE CT
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7635
Practice Address - Country:US
Practice Address - Phone:844-656-8763
Practice Address - Fax:847-556-1715
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098347207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098347Medicaid
IL406120043OtherMEDICARE PTAN FOR SCMG
IL036098347Medicaid
IL389780Medicare ID - Type Unspecified
IL406120043OtherMEDICARE PTAN FOR SCMG
IL036098347Medicaid