Healthcare Provider Details

I. General information

NPI: 1346949674
Provider Name (Legal Business Name): MICHAEL XAVIER PANAMENO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

1731 E 118TH ST
LOS ANGELES CA
90059-2517
US

V. Phone/Fax

Practice location:
  • Phone: 323-563-4800
  • Fax:
Mailing address:
  • Phone: 323-563-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA199141
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: