Healthcare Provider Details

I. General information

NPI: 1477631661
Provider Name (Legal Business Name): QUINN MARTIN FAURIA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18433 ROSCOE BLVD STE 214
NORTHRIDGE CA
91325-4123
US

IV. Provider business mailing address

18433 ROSCOE BLVD STE 214
NORTHRIDGE CA
91325-4123
US

V. Phone/Fax

Practice location:
  • Phone: 818-623-4455
  • Fax: 818-985-0055
Mailing address:
  • Phone: 818-623-4455
  • Fax: 818-985-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4140
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: