Healthcare Provider Details

I. General information

NPI: 1346400348
Provider Name (Legal Business Name): THEOGNOSIA PAPASOZOMENOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 12/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 COLONIAL DR FAMILY & PREVENTIVE MEDICINE
COLUMBIA SC
29203-6930
US

IV. Provider business mailing address

820 SCENIC DR
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6113
  • Fax: 803-434-7231
Mailing address:
  • Phone: 803-434-6113
  • Fax: 803-434-7231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberC158285
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberLL38568
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: