Healthcare Provider Details

I. General information

NPI: 1972982239
Provider Name (Legal Business Name): BENJAMIN FEGALE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 MAGNOLIA AVE
RIVERSIDE CA
92504-3849
US

IV. Provider business mailing address

7300 MAGNOLIA AVE
RIVERSIDE CA
92504-3849
US

V. Phone/Fax

Practice location:
  • Phone: 951-278-8870
  • Fax: 951-379-5310
Mailing address:
  • Phone: 951-278-8870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA149742
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA149972
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: