Provider Demographics
NPI:1255313458
Name:PANAGIOTIS, NICHOLAS MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:PANAGIOTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18370 BURBANK BLVD
Mailing Address - Street 2:507
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2804
Mailing Address - Country:US
Mailing Address - Phone:818-774-9200
Mailing Address - Fax:
Practice Address - Street 1:18370 BURBANK BLVD
Practice Address - Street 2:507
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2804
Practice Address - Country:US
Practice Address - Phone:818-774-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23551174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A235510Medicaid
CA00A235510Medicaid
CAA23551Medicare ID - Type Unspecified