Provider Demographics
NPI:1427154590
Name:THEODOROU, MARIA S (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:S
Last Name:THEODOROU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-5840
Mailing Address - Country:US
Mailing Address - Phone:520-694-2700
Mailing Address - Fax:
Practice Address - Street 1:265 W INA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-6204
Practice Address - Country:US
Practice Address - Phone:520-694-8100
Practice Address - Fax:520-694-8191
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21212208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ125262Medicaid
AZ23999Medicare ID - Type Unspecified
AZF48874Medicare UPIN