Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | MA64903 | NJ |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | MA64903 | NJ |
NPI | 1235212879 |
---|---|
Provider Name | Dr. Stefanos Pantagis |
First Address | Englewood, NJ 07631-3054 |
Second Address | Hackensack, NJ 07601-4847 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2006 |
Last Update Date | 05/02/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6818706 | (05) | NJ |
G92410 | (02) | NJ |