Provider Demographics
NPI:1114949179
Name:PANAKOS, CONSTANTINE PAUL (DO)
Entity Type:Individual
Prefix:
First Name:CONSTANTINE
Middle Name:PAUL
Last Name:PANAKOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 N MULBERRY RD
Mailing Address - Street 2:TANGLEWOOD MEDICAL CLINIC, PA
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3532
Mailing Address - Country:US
Mailing Address - Phone:316-788-3787
Mailing Address - Fax:316-788-2618
Practice Address - Street 1:606 N MULBERRY RD
Practice Address - Street 2:TANGLEWOOD MEDICAL CENTER, PA
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3532
Practice Address - Country:US
Practice Address - Phone:316-788-3787
Practice Address - Fax:316-788-2618
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0530413207Q00000X
IA3867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
71590OtherBCBS
IA1114949179Medicaid
KSI04385Medicare UPIN