Healthcare Provider Details

I. General information

NPI: 1235407206
Provider Name (Legal Business Name): BASIL C THEODOTOU MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 SUNTREE PL
MELBOURNE FL
32940-7689
US

IV. Provider business mailing address

32 SUNTREE PL
MELBOURNE FL
32940-7689
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-7001
  • Fax: 321-254-1776
Mailing address:
  • Phone: 321-752-7001
  • Fax: 321-254-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberME0046303
License Number StateFL

VIII. Authorized Official

Name: BASIL THEODOTOU
Title or Position: OWNER
Credential: MD
Phone: 321-752-7001