Basic Information
| Provider Information | |||||||||
| NPI: | 1669444972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEODOROU | ||||||||
| FirstName: | SPERO | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 941 MCLEAN AVE | ||||||||
| Address2: | # 387 | ||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107044107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142376797 | ||||||||
| FaxNumber: | 2082798681 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 CENTRAL PARK S | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122652724 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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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 | 208200000X | 228653 | NY | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0063771 | 05 | NJ | MEDICAID |