Provider Demographics
NPI:1194965558
Name:KOKTSIDIS, THEODORA (HEALTH ADMINISTRATOR)
Entity type:Individual
Prefix:MS
First Name:THEODORA
Middle Name:
Last Name:KOKTSIDIS
Suffix:
Gender:F
Credentials:HEALTH ADMINISTRATOR
Other - Prefix:MS
Other - First Name:THEODORA
Other - Middle Name:
Other - Last Name:KOKTSIDIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MEDICAL ASSISTANT
Mailing Address - Street 1:346 FOX TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-2351
Mailing Address - Country:US
Mailing Address - Phone:219-677-7018
Mailing Address - Fax:219-940-9429
Practice Address - Street 1:346 FOX TRAIL CT
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-2351
Practice Address - Country:US
Practice Address - Phone:219-677-7018
Practice Address - Fax:219-940-9429
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker