Healthcare Provider Details

I. General information

NPI: 1285964239
Provider Name (Legal Business Name): ELLYN FRANCES THEOPHILOPOULOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELLYN FRANCES PALERMO MD

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 WOODLANDS PKWY STE B
PALM HARBOR FL
34685-3495
US

IV. Provider business mailing address

150 N SPRING BLVD
TARPON SPRINGS FL
34689-3247
US

V. Phone/Fax

Practice location:
  • Phone: 727-772-1452
  • Fax:
Mailing address:
  • Phone: 727-946-9062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0068251
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: