Provider Demographics
NPI:1740302868
Name:PANAGOTACOS, PETER JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:PANAGOTACOS
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 1:2001 UNION ST
Mailing Address - Street 2:SUITE #520
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-4114
Mailing Address - Country:US
Mailing Address - Phone:415-922-3344
Mailing Address - Fax:415-921-7759
Practice Address - Street 1:2001 UNION ST
Practice Address - Street 2:SUITE #520
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-4114
Practice Address - Country:US
Practice Address - Phone:415-922-3344
Practice Address - Fax:415-921-7759
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36061207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ53573ZOtherANTHEM
CAA36156Medicare UPIN
CAZZZ28290ZMedicare PIN