Provider Demographics
NPI:1861771735
Name:THEOPHANOUS, STELIOS
Entity type:Individual
Prefix:
First Name:STELIOS
Middle Name:
Last Name:THEOPHANOUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 NEALY AVE
Mailing Address - Street 2:633RD MEDICAL GROUP
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:330-518-7129
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY AVE
Practice Address - Street 2:633RD MEDICAL GROUP
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:330-518-7129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0323368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist