Individual
DR. ANTHONY C THEODORIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1500 ROUTE 112 STE B, PORT JEFFERSON STATION, NY 11776-8054
(631) 978-7633
(631) 638-4884
Mailing address
45 RESEARCH WAY STE 208A, EAST SETAUKET, NY 11733-6401
(631) 675-2125
(631) 675-2628
Taxonomy
Speciality
Code
Description
License number
State
207RP1001X
Pulmonary Disease Physician
Primary
221756-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02732167
—
NY
01
—
7V691EC831
MEDICARE OTHER PIN
NY
Enumeration date
08/31/2006
Last updated
04/29/2022
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