Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 228456 | MA |
N | 111NI0900X | Internist | 228456 | MA |
N | 207R00000X | Internist | A106957 | CA |
N | 111NI0900X | Internist | A106957 | CA |
Y | 207RI0200X | Infectious Disease | A106957 | CA |
NPI | 1043487317 |
---|---|
Provider Name | Dr. Theodoros Kelesidis |
First Address | Los Angeles, CA 90095-0001 |
Second Address | Los Angeles, CA 90095-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2008 |
Last Update Date | 14/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1043487317 | (05) | CA |