Provider Demographics
NPI:1467429720
Name:PANTAZIS, COOLEY G (MD)
Entity Type:Individual
Prefix:
First Name:COOLEY
Middle Name:G
Last Name:PANTAZIS
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:PO BOX 63069
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-3069
Mailing Address - Country:US
Mailing Address - Phone:352-351-7263
Mailing Address - Fax:352-622-3672
Practice Address - Street 1:1500 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6504
Practice Address - Country:US
Practice Address - Phone:352-351-7262
Practice Address - Fax:352-402-5047
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75579207SC0300X, 207ZC0500X, 207ZH0000X, 207ZI0100X, 207ZP0007X, 207ZP0101X, 207ZP0105X
GA022259207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Cytogenetics
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathology
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD40800Medicare UPIN
FL43571Medicare PIN