Provider Demographics
NPI:1760487961
Name:THEODOTOU, BASIL (MD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:
Last Name:THEODOTOU
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 1:32 SUNTREE PL
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7689
Mailing Address - Country:US
Mailing Address - Phone:321-752-7001
Mailing Address - Fax:321-254-1776
Practice Address - Street 1:32 SUNTREE PL
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7689
Practice Address - Country:US
Practice Address - Phone:321-752-7001
Practice Address - Fax:321-254-1776
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046303207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041713100Medicaid
FL041713100Medicaid
FL05565Medicare ID - Type Unspecified