Provider Demographics
NPI:1548600224
Name:PANDAMOUZ, ALI (MD)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:PANDAMOUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4932
Mailing Address - Country:US
Mailing Address - Phone:209-823-3111
Mailing Address - Fax:
Practice Address - Street 1:1205 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4932
Practice Address - Country:US
Practice Address - Phone:209-823-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA136965207Q00000X, 207P00000X
IL036.153861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine