Provider Demographics
NPI:1124120498
Name:THEODOROPOULOS, DIMITRA (MD, FACS)
Entity type:Individual
Prefix:
First Name:DIMITRA
Middle Name:
Last Name:THEODOROPOULOS
Suffix:
Gender:F
Credentials:MD, FACS
Other - Prefix:
Other - First Name:DIMITRA
Other - Middle Name:
Other - Last Name:BARABOUTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 E SHORE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-2410
Mailing Address - Country:US
Mailing Address - Phone:516-482-8657
Mailing Address - Fax:516-829-0002
Practice Address - Street 1:310 E SHORE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2410
Practice Address - Country:US
Practice Address - Phone:516-482-8657
Practice Address - Fax:516-829-0002
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081475208600000X, 208C00000X
NY251938208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery