Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | P1628 | TX |
N | 207KA0200X | Allergist | P1628 | TX |
NPI | 1700140969 |
---|---|
Provider Name | Christodoulos S Christodoulou |
First Address | Bandera, TX 78009 |
Second Address | Bandera, TX 78009 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2012 |
Last Update Date | 05/01/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
304287YT5K | MEDICARE (01) | TX |