Healthcare Provider Details

I. General information

NPI: 1033805791
Provider Name (Legal Business Name): COSTINA MAI-LY PAPATHEODOROU DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7211 W DESCHUTES AVE STE B
KENNEWICK WA
99336-7715
US

IV. Provider business mailing address

7211 W DESCHUTES AVE STE B
KENNEWICK WA
99336-7715
US

V. Phone/Fax

Practice location:
  • Phone: 509-221-6930
  • Fax:
Mailing address:
  • Phone: 509-221-6930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO.OP.7010121
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: