Healthcare Provider Details

I. General information

NPI: 1689622177
Provider Name (Legal Business Name): JERRY M FABRIKANT D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR BLDG 3 # 353
LA MESA CA
91942-3007
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DR BLDG 3 #353
LA MESA CA
91942-3007
US

V. Phone/Fax

Practice location:
  • Phone: 619-465-3443
  • Fax: 619-466-7311
Mailing address:
  • Phone: 619-465-3443
  • Fax: 619-466-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number000E23120
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000E23120
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: