Provider Demographics
NPI:1922009059
Name:THEODORAKIS, SPYRIDON P (MD)
Entity Type:Individual
Prefix:
First Name:SPYRIDON
Middle Name:P
Last Name:THEODORAKIS
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 1:5011 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2611
Mailing Address - Country:US
Mailing Address - Phone:773-561-7710
Mailing Address - Fax:773-561-7760
Practice Address - Street 1:5011 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2611
Practice Address - Country:US
Practice Address - Phone:773-561-7710
Practice Address - Fax:773-561-7760
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058530208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1617875OtherBLUE CROSS BLUE SHIELD
IL36058530Medicaid
770350Medicare ID - Type Unspecified
IL1617875OtherBLUE CROSS BLUE SHIELD