Provider Demographics
NPI:1952396897
Name:MAVROUDIS, CONSTANTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:CONSTANTINE
Middle Name:
Last Name:MAVROUDIS
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 1:2501 N. ORANGE AVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804
Mailing Address - Country:US
Mailing Address - Phone:407-303-3692
Mailing Address - Fax:407-303-3634
Practice Address - Street 1:2501 N. ORANGE AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804
Practice Address - Country:US
Practice Address - Phone:407-303-3692
Practice Address - Fax:407-303-3634
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0924532086S0120X
FLME112169208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXPY198252Medicaid
FL004570600Medicaid
IL1627123OtherBCBS PROVIDER ID
KY64213531Medicaid
IL036079315Medicaid
OH2865896Medicaid
WVCSF715Medicaid
ILL83651Medicare PIN
FL004570600Medicaid
IL1627123OtherBCBS PROVIDER ID
KY64213531Medicaid