Healthcare Provider Details

I. General information

NPI: 1700889748
Provider Name (Legal Business Name): PANAGIOTIS FOURTOUNIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PANOS FOURTOUNIS MD

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14406 NE 20TH AVE
VANCOUVER WA
98686-1448
US

IV. Provider business mailing address

820 NW 12TH AVE APT 516
PORTLAND OR
97209-3042
US

V. Phone/Fax

Practice location:
  • Phone: 360-418-6001
  • Fax:
Mailing address:
  • Phone: 503-539-8519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD00044865
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: