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General NPI Number Information
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NPI Number | 1295999274
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Entity Type | Organization
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Legal Business Name | DAPHNE I PANAGOTACOS MD
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Dates
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Enumeration Date | 07/18/2008
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Last Update Date | 07/31/2012
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Provider Practice Location Address
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Address Line | 32144 AGOURA RD SUITE 106
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City | WESTLAKE VILLAGE
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State | CA
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Zip | 91361-4031
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Country | US
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Telephone | 805-379-3376
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Fax | 805-379-3267
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Provider Business Mailing Address
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Address Line | 32144 AGOURA RD SUITE 106
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City | WESTLAKE VILLAGE
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State | CA
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Zip | 91361-4031
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Country | US
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Telephone | 805-379-3376
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Fax | 805-379-3267
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MS. DEBBIE ICKES
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Credential |
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Telephone | 805-379-3376
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | G66971
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207NP0225X
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Taxonomy Name | Pediatric Dermatology Physician
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License Number | G66971
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number | G66971
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License Number State | CA
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