Provider Demographics
NPI:1811091069
Name:PANAGOTACOS, DAPHNE I (MD)
Entity type:Individual
Prefix:DR
First Name:DAPHNE
Middle Name:I
Last Name:PANAGOTACOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32144 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
Is Sole Proprietor?:No
Enumeration Date:2006-09-09
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66971207N00000X, 207ND0101X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G66971Medicare ID - Type Unspecified
F81669Medicare UPIN