Provider Demographics
NPI:1720174055
Name:THEODOULOU, MARIA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:THEODOULOU
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 1:400 PATROON CREEK BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-5013
Mailing Address - Country:US
Mailing Address - Phone:518-489-0044
Mailing Address - Fax:518-489-3591
Practice Address - Street 1:400 PATROON CREEK BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-5013
Practice Address - Country:US
Practice Address - Phone:518-489-0044
Practice Address - Fax:518-489-3591
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183499207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03577891Medicaid
NYJ400299001Medicare PIN
F72322Medicare UPIN