Basic Information
| Provider Information | |||||||||
| NPI: | 1720174055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEODOULOU | ||||||||
| FirstName: | MARIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 PATROON CREEK BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122065013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184890044 | ||||||||
| FaxNumber: | 5184893591 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 PATROON CREEK BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122065013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184890044 | ||||||||
| FaxNumber: | 5184893591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 183499 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 03577891 | 05 | NY | MEDICAID |