Provider Demographics
NPI:1578675971
Name:THEODORIS, ANTHONY C (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:C
Last Name:THEODORIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:45 RESEARCH WAY STE 208A
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-6401
Mailing Address - Country:US
Mailing Address - Phone:631-675-2125
Mailing Address - Fax:631-675-2628
Practice Address - Street 1:1500 ROUTE 112 STE B
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8054
Practice Address - Country:US
Practice Address - Phone:631-978-7633
Practice Address - Fax:631-638-4884
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-04-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY221756-1207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7V691EC831OtherMEDICARE OTHER PIN
NY02732167Medicaid
NY02732167Medicaid
NY7V6910Medicare PIN