=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740378280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAPHNE I PANAGOTACOS MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 LA VENTA DR SUITE 105
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-3758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-379-3376
-----------------------------------------------------
Fax | 805-379-3267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 LA VENTA DR SUITE 105
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-3758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-379-3376
-----------------------------------------------------
Fax | 805-379-3267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAPHNE IRMGARD PANAGOTACOS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 805-379-3376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G66971
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------