Provider Demographics
NPI:1962408765
Name:PANTAZELOS, HYTHO H (MD)
Entity type:Individual
Prefix:
First Name:HYTHO
Middle Name:H
Last Name:PANTAZELOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ORNAC
Mailing Address - Street 2:STE 510
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4162
Mailing Address - Country:US
Mailing Address - Phone:978-369-8777
Mailing Address - Fax:
Practice Address - Street 1:131 ORNAC
Practice Address - Street 2:STE 510
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4162
Practice Address - Country:US
Practice Address - Phone:978-369-8777
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
MA29312208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2010321Medicaid