Provider Demographics
NPI:1578675864
Name:PANOUSIERIS, EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:PANOUSIERIS
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 1:2696 N GALLOWAY AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150
Mailing Address - Country:US
Mailing Address - Phone:972-613-5500
Mailing Address - Fax:972-613-5015
Practice Address - Street 1:2696 N GALLOWAY AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:972-613-5500
Practice Address - Fax:972-613-5015
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2665207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097269702OtherTPI
TX097269702Medicaid
TX097269702Medicaid
00A67KMedicare ID - Type Unspecified