Healthcare Provider Details

I. General information

NPI: 1174656102
Provider Name (Legal Business Name): FERNANDO BASCO CANON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8337 TELEGRAPH RD SUITE 210
PICO RIVERA CA
90660-4909
US

IV. Provider business mailing address

8337 TELEGRAPH RD SUITE 210
PICO RIVERA CA
90660-4909
US

V. Phone/Fax

Practice location:
  • Phone: 562-806-1321
  • Fax: 562-806-0801
Mailing address:
  • Phone: 562-806-1321
  • Fax: 562-806-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA30070
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: