Healthcare Provider Details

I. General information

NPI: 1649583071
Provider Name (Legal Business Name): DANIEL MATTHEW FENTRESS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

IV. Provider business mailing address

595 CENTER AVE SUITE 300
MARTINEZ CA
94553-4633
US

V. Phone/Fax

Practice location:
  • Phone: 925-370-5110
  • Fax: 925-370-5142
Mailing address:
  • Phone: 925-313-6098
  • Fax: 925-313-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA109455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: