Provider Demographics
NPI:1528152170
Name:ECONOMOU, THEMISTOCLES PETER (MD)
Entity type:Individual
Prefix:
First Name:THEMISTOCLES
Middle Name:PETER
Last Name:ECONOMOU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 110N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-2001
Mailing Address - Country:US
Mailing Address - Phone:651-602-5309
Mailing Address - Fax:651-222-6786
Practice Address - Street 1:7760 FRANCE AVE S STE 1000
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55435-5870
Practice Address - Country:US
Practice Address - Phone:952-746-6767
Practice Address - Fax:952-746-6768
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN37341208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN384325400Medicaid
MN384325400Medicaid
MN020001127Medicare ID - Type Unspecified