Provider Demographics
NPI:1730328691
Name:THEODOSATOS, ATHENA (DO MPH)
Entity type:Individual
Prefix:DR
First Name:ATHENA
Middle Name:
Last Name:THEODOSATOS
Suffix:
Gender:F
Credentials:DO MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 E SEMORAN BLVD STE 258
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-5900
Mailing Address - Country:US
Mailing Address - Phone:407-671-3634
Mailing Address - Fax:407-986-6033
Practice Address - Street 1:3030 E SEMORAN BLVD STE 258
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-5900
Practice Address - Country:US
Practice Address - Phone:407-671-3634
Practice Address - Fax:407-986-6033
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-16
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10497207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL146TMOtherBCBSFL
FL001101800Medicaid
FL001101800Medicaid
FL146TMOtherBCBSFL