Provider Demographics
NPI:1295999274
Name:DAPHNE I PANAGOTACOS MD
Entity type:Organization
Organization Name:DAPHNE I PANAGOTACOS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ICKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-379-3376
Mailing Address - Street 1:32144 AGOURA RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-4031
Mailing Address - Country:US
Mailing Address - Phone:805-379-3376
Mailing Address - Fax:805-379-3267
Practice Address - Street 1:32144 AGOURA RD
Practice Address - Street 2:SUITE 106
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-4031
Practice Address - Country:US
Practice Address - Phone:805-379-3376
Practice Address - Fax:805-379-3267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66971207ND0101X, 207NP0225X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG66971Medicare PIN
CAF81669Medicare UPIN