Basic Information
| Provider Information | |||||||||
| NPI: | 1144265315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STATHOS | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | HARRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9224 TEDDY LN | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801246798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037901515 | ||||||||
| FaxNumber: | 3037901989 | ||||||||
| Practice Location | |||||||||
| Address1: | 9224 TEDDY LANE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801246799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037901515 | ||||||||
| FaxNumber: | 3037901989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 09/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 33634 | CO | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 04018362 | 01 | CO | GROUP MEDICAID | OTHER | 1144265315 | 05 | WY | MEDICAID | 200293420 A | 01 | OK | GROUP MEDICAID | OTHER | 200295450 A | 05 | OK | MEDICAID | 33634 | 01 | CO | MEDICAL LICENSE | OTHER | 109864100 | 01 | WY | GROUP MEDICAID | OTHER | 01336346 | 05 | CO | MEDICAID | 1699895755 | 01 | GROUP NPI | OTHER | 18498 | 01 | NE | MEDICAL LICENSE | OTHER | 8301A | 01 | WY | MEDICAL LICENSE | OTHER | 84127410413 | 01 | NE | GROUP MEDICAID | OTHER |