Provider Demographics
NPI:1760430755
Name:THEODOULOU, MICHAEL HERCULES (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HERCULES
Last Name:THEODOULOU
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1408
Mailing Address - Country:US
Mailing Address - Phone:617-665-1000
Mailing Address - Fax:
Practice Address - Street 1:230 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1408
Practice Address - Country:US
Practice Address - Phone:617-665-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPO558213E00000X
MD01073213E00000X
MA2358213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110084502AMedicaid
MA110084502AMedicaid
MDU28344Medicare UPIN
MA0014612Medicare PIN
MD607382Medicare ID - Type Unspecified