Healthcare Provider Details

I. General information

NPI: 1851578819
Provider Name (Legal Business Name): JERRY M FABRIKANT DPM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

5565 GROSSMONT CENTER DR BLDG 3 STE 353
LA MESA CA
91942-3020
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 Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: JERRY M FABRIKANT
Title or Position: PRESIDENT
Credential: DPM
Phone: 619-465-3443