MEDICARE: DR. MICHAEL HERCULES THEODOULOU D.P.M.

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	213E00000X	Podiatrist	PO558	DC
2	213E00000X	Podiatrist	01073	MD
3	213E00000X	Podiatrist	2358	MA

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	:	1760430755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL HERCULES THEODOULOU D.P.M.

Provider Business Mailing Address
First Line	:	230 HIGHLAND AVE
Second Line	:
City	:	SOMERVILLE
State	:	MA
Zip	:	02143-1408
Country	:	US
Telephone Number	:	617-665-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 HIGHLAND AVE
Second Line	:
City	:	SOMERVILLE
State	:	MA
Zip	:	02143-1408
Country	:	US
Telephone Number	:	617-665-1000
Fax Number	:

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	12/08/2011

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