Healthcare Provider Details

I. General information

NPI: 1568464048
Provider Name (Legal Business Name): FARO OWIESY M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: FARO T OWIESY M.D

II. Dates (important events)

Enumeration Date: 08/13/2005
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date: 03/22/2006
Reactivation Date: 03/31/2006

III. Provider practice location address

1820 FULLERTON AVE STE 120
CORONA CA
92881-3100
US

IV. Provider business mailing address

802 MAGNOLIA AVE STE 106
CORONA CA
92879-3125
US

V. Phone/Fax

Practice location:
  • Phone: 951-371-9500
  • Fax: 951-371-9194
Mailing address:
  • Phone: 951-371-9500
  • Fax: 951-278-8182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA87796
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA87796
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: