Provider Demographics
NPI:1932075207
Name:THEODOSOPOULOS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THEODOSOPOULOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2138
Mailing Address - Country:US
Mailing Address - Phone:773-414-9992
Mailing Address - Fax:
Practice Address - Street 1:1409 MADISON ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2138
Practice Address - Country:US
Practice Address - Phone:773-414-9992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-14
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.033529363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner