Provider Demographics
NPI:1700889748
Name:FOURTOUNIS, PANAGIOTIS (MD)
Entity Type:Individual
Prefix:DR
First Name:PANAGIOTIS
Middle Name:
Last Name:FOURTOUNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PANOS
Other - Middle Name:
Other - Last Name:FOURTOUNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:820 NW 12TH AVE
Mailing Address - Street 2:APT 516
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3042
Mailing Address - Country:US
Mailing Address - Phone:503-539-8519
Mailing Address - Fax:
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:360-418-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044865174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8933360Medicaid
NC8933360Medicaid
NC2229737AMedicare ID - Type Unspecified