Healthcare Provider Details

I. General information

NPI: 1487085841
Provider Name (Legal Business Name): PEJMAN FANI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N EL CAMINO REAL STE 201
ENCINITAS CA
92024-2813
US

IV. Provider business mailing address

PO BOX 910252
SAN DIEGO CA
92191-0252
US

V. Phone/Fax

Practice location:
  • Phone: 760-566-6841
  • Fax:
Mailing address:
  • Phone: 714-585-4843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A13052
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A13052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: