Healthcare Provider Details

I. General information

NPI: 1124120498
Provider Name (Legal Business Name): DIMITRA THEODOROPOULOS M.D., FACS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIMITRA BARABOUTI

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E SHORE RD SUITE 203
GREAT NECK NY
11023-2410
US

IV. Provider business mailing address

310 E SHORE RD SUITE 203
GREAT NECK NY
11023-2410
US

V. Phone/Fax

Practice location:
  • Phone: 516-482-8657
  • Fax: 516-829-0002
Mailing address:
  • Phone: 516-482-8657
  • Fax: 516-829-0002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301081475
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number4301081475
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number251938
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number251938
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: