Provider Demographics
NPI:1669444972
Name:THEODOROU, SPERO JOHN (MD)
Entity Type:Individual
Prefix:
First Name:SPERO
Middle Name:JOHN
Last Name:THEODOROU
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 1:941 MCLEAN AVE
Mailing Address - Street 2:# 387
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-4107
Mailing Address - Country:US
Mailing Address - Phone:914-237-6797
Mailing Address - Fax:208-279-8681
Practice Address - Street 1:128 CENTRAL PARK S
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1565
Practice Address - Country:US
Practice Address - Phone:212-265-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228653208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0063771Medicaid
FL41157XMedicare PIN
NJ096520Medicare ID - Type Unspecified
NYA400029732Medicare PIN
H72653Medicare UPIN
NJ0063771Medicaid
NJ087686SU7Medicare PIN
FL41157ZMedicare PIN
NY1539FET041Medicare PIN