Provider Demographics
NPI:1538199369
Name:THEOTOKATOS, LINDA (DO)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:
Last Name:THEOTOKATOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6648
Mailing Address - Country:US
Mailing Address - Phone:716-204-0707
Mailing Address - Fax:716-204-0693
Practice Address - Street 1:5430 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6648
Practice Address - Country:US
Practice Address - Phone:716-204-0707
Practice Address - Fax:716-204-0693
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2135991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105719Medicaid
IL363149833OtherTAX IDENTIFICATION NUMBER
ILH22258Medicare UPIN
IL0222075OtherBLUE CROSS GROUP NUMBER
IL548190Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER