Provider Demographics
NPI:1669478293
Name:KOMODROMOS, THEMIS (MD)
Entity Type:Individual
Prefix:
First Name:THEMIS
Middle Name:
Last Name:KOMODROMOS
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 1:1613 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1849
Mailing Address - Country:US
Mailing Address - Phone:407-894-4474
Mailing Address - Fax:407-894-7136
Practice Address - Street 1:1613 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1849
Practice Address - Country:US
Practice Address - Phone:407-894-4474
Practice Address - Fax:407-894-7136
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0091359207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
I24521Medicare UPIN