Healthcare Provider Details

I. General information

NPI: 1407824600
Provider Name (Legal Business Name): LUIS A. FIALLO M.D., F.A.C.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 ROSS AVE
EL CENTRO CA
92243-4306
US

IV. Provider business mailing address

23845 MCBEAN PKWY
VALENCIA CA
91355-2001
US

V. Phone/Fax

Practice location:
  • Phone: 760-339-7202
  • Fax: 760-339-9904
Mailing address:
  • Phone: 661-200-1122
  • Fax: 661-200-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberC51309
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberC51309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: