Provider Demographics
NPI:1316987019
Name:PANAGIOTOU, NICHOLAS D (MD, PHD, MS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:D
Last Name:PANAGIOTOU
Suffix:
Gender:M
Credentials:MD, PHD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 115
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07451-0115
Mailing Address - Country:US
Mailing Address - Phone:201-447-3690
Mailing Address - Fax:201-447-3691
Practice Address - Street 1:385 SOUTH MAPLE AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-447-3690
Practice Address - Fax:201-447-3691
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO7320300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8751102Medicaid
NJ8751102Medicaid
NJ087305Medicare ID - Type Unspecified
NJ087299Medicare ID - Type UnspecifiedNEW JERSEY KEYSTONE PHYSI