Provider Demographics
NPI:1861444846
Name:THEOFILOS, CHARLES S (MD PA)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:S
Last Name:THEOFILOS
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 VILLAGE SQUARE XING STE 202
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3223
Mailing Address - Country:US
Mailing Address - Phone:561-630-3870
Mailing Address - Fax:561-630-3680
Practice Address - Street 1:300 VILLAGE SQUARE XING STE 202
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-3223
Practice Address - Country:US
Practice Address - Phone:561-630-3870
Practice Address - Fax:561-630-3680
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064328207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373280100Medicaid
FL373280100Medicaid
F64121Medicare UPIN