Healthcare Provider Details

I. General information

NPI: 1740302868
Provider Name (Legal Business Name): PETER JOHN PANAGOTACOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 UNION ST SUITE #520
SAN FRANCISCO CA
94123-4114
US

IV. Provider business mailing address

2001 UNION ST SUITE #520
SAN FRANCISCO CA
94123-4114
US

V. Phone/Fax

Practice location:
  • Phone: 415-922-3344
  • Fax: 415-921-7759
Mailing address:
  • Phone: 415-922-3344
  • Fax: 415-921-7759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC36061
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberC36061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: