Healthcare Provider Details

I. General information

NPI: 1649565771
Provider Name (Legal Business Name): ALEXANDER ANTONIOS THEOLOGIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARNASSUS AVE MU320
SAN FRANCISCO CA
94143
US

IV. Provider business mailing address

660 S EUCLID AVE
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-8203
  • Fax:
Mailing address:
  • Phone: 650-996-6651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number2017010211
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA124464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: