Provider Demographics
NPI:1790014942
Name:FOTOPOULOS, EVANGELIA (MD)
Entity Type:Individual
Prefix:
First Name:EVANGELIA
Middle Name:
Last Name:FOTOPOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 S HARBOR CITY BLVD
Mailing Address - Street 2:STE 440
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5591
Mailing Address - Country:US
Mailing Address - Phone:321-541-1744
Mailing Address - Fax:321-725-4183
Practice Address - Street 1:2222 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 430
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5594
Practice Address - Country:US
Practice Address - Phone:321-541-1777
Practice Address - Fax:321-725-5504
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL.3075R207Q00000X
FLME112559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005580100Medicaid
FL005580100Medicaid