1295814275 NPI number — PANAGIOTIS P BOUGAS M.D.

Table of content: PANAGIOTIS P BOUGAS M.D. (NPI 1295814275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295814275 NPI number — PANAGIOTIS P BOUGAS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUGAS
Provider First Name:
PANAGIOTIS
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MPOUGAS
Provider Other First Name:
PANAGIOTIS
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1295814275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 LAGUNA RD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
FULLERTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92835-2523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-446-7454
Provider Business Mailing Address Fax Number:
714-879-1049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 LAGUNA RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835-2523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-446-7454
Provider Business Practice Location Address Fax Number:
714-879-1049
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G84424 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0200X , with the licence number: G84424 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: G84424 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G84424 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0014371 . This is a "MEDI-CAL PROV I.D." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 290011505 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ97067Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com