MEDICARE: DR. ELLYN FRANCES THEOPHILOPOULOS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME0068251	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285964239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLYN FRANCES THEOPHILOPOULOS MD

Provider Business Mailing Address
First Line	:	150 N SPRING BLVD
Second Line	:
City	:	TARPON SPRINGS
State	:	FL
Zip	:	34689-3247
Country	:	US
Telephone Number	:	727-946-9062
Fax Number	:

Provider Business Practice Location Address
First Line	:	4150 WOODLANDS PKWY STE B
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-3495
Country	:	US
Telephone Number	:	727-772-1452
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2010
Last Update Date	:	01/13/2010

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