Provider Demographics
NPI:1295814275
Name:BOUGAS, PANAGIOTIS P (MD)
Entity Type:Individual
Prefix:
First Name:PANAGIOTIS
Middle Name:P
Last Name:BOUGAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PANAGIOTIS
Other - Middle Name:P
Other - Last Name:MPOUGAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:220 LAGUNA RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2523
Mailing Address - Country:US
Mailing Address - Phone:714-446-7454
Mailing Address - Fax:714-879-1049
Practice Address - Street 1:220 LAGUNA RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2523
Practice Address - Country:US
Practice Address - Phone:714-446-7454
Practice Address - Fax:714-879-1049
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84424207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG84424OtherSTATE LICENSE
CAGR0014371OtherMEDI-CAL PROV I.D.
CA290011505OtherRAILROAD MEDICARE
CAZZZ97067ZOtherBLUE SHIELD
CAF95268Medicare UPIN
CAWG84424AMedicare ID - Type UnspecifiedMEDICARE PROV I.D.