Provider Demographics
NPI:1811972953
Name:PANOSIAN, S GREG (OD)
Entity type:Individual
Prefix:DR
First Name:S
Middle Name:GREG
Last Name:PANOSIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1804
Mailing Address - Country:US
Mailing Address - Phone:818-956-1010
Mailing Address - Fax:818-543-6083
Practice Address - Street 1:607 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1804
Practice Address - Country:US
Practice Address - Phone:818-956-1010
Practice Address - Fax:818-543-6083
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8301T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ75843ZMedicaid
CAZZZ75843ZMedicaid
W13790Medicare ID - Type Unspecified