Healthcare Provider Details

I. General information

NPI: 1871692434
Provider Name (Legal Business Name): THEODOROU PLASTIC SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 CENTRAL PARK S
NEW YORK NY
10019-1565
US

IV. Provider business mailing address

976 MCLEAN AVE SUITE 387
YONKERS NY
10704-4105
US

V. Phone/Fax

Practice location:
  • Phone: 914-237-6797
  • Fax: 914-237-6790
Mailing address:
  • Phone: 914-237-6797
  • Fax: 914-206-4950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number228653-1
License Number StateNY

VIII. Authorized Official

Name: SPERO JOHN THEODOROU
Title or Position: DIRECTOR
Credential: MD
Phone: 914-237-6797