Provider Demographics
NPI:1790898880
Name:THEODOROU, KEVIN PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PHILIP
Last Name:THEODOROU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10585 N TATUM BLVD
Mailing Address - Street 2:D-137
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1073
Mailing Address - Country:US
Mailing Address - Phone:602-277-2361
Mailing Address - Fax:602-713-9999
Practice Address - Street 1:10585 N TATUM BLVD
Practice Address - Street 2:D-137
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-1073
Practice Address - Country:US
Practice Address - Phone:602-277-2361
Practice Address - Fax:602-713-9999
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ28436207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ639677Medicaid
AZ639677Medicaid
AZG84591Medicare UPIN
AZ68270Medicare ID - Type UnspecifiedGROUP NUMBER