Healthcare Provider Details

I. General information

NPI: 1528528569
Provider Name (Legal Business Name): ELIAS JASON FANOUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 CITRACADO PKWY STE 220
ESCONDIDO CA
92029-4151
US

IV. Provider business mailing address

2130 CITRACADO PKWY STE 220
ESCONDIDO CA
92029-4151
US

V. Phone/Fax

Practice location:
  • Phone: 760-743-0546
  • Fax: 760-317-9769
Mailing address:
  • Phone: 951-902-9475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA179829
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA179829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: