Basic Information
| Provider Information | |||||||||
| NPI: | 1063686624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THEODOROU | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | WESLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POTTS | ||||||||
| OtherFirstName: | WILLIAM | ||||||||
| OtherMiddleName: | WESLEY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | III | ||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1653 W CONGRESS PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129425495 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1653 W CONGRESS PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129425495 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 02/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 125.055740 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036.130614 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.