Provider Demographics
NPI:1285964239
Name:THEOPHILOPOULOS, ELLYN FRANCES (MD)
Entity type:Individual
Prefix:DR
First Name:ELLYN
Middle Name:FRANCES
Last Name:THEOPHILOPOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELLYN
Other - Middle Name:FRANCES
Other - Last Name:PALERMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:150 N SPRING BLVD
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-3247
Mailing Address - Country:US
Mailing Address - Phone:727-946-9062
Mailing Address - Fax:
Practice Address - Street 1:4150 WOODLANDS PKWY STE B
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-3495
Practice Address - Country:US
Practice Address - Phone:727-772-1452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068251208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377708100Medicaid