Healthcare Provider Details

I. General information

NPI: 1497857460
Provider Name (Legal Business Name): JOHN E. FELLOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15025 INNOVATION DR
SAN DIEGO CA
92128-3409
US

IV. Provider business mailing address

54433 FILE
LOS ANGELES CA
90074-0001
US

V. Phone/Fax

Practice location:
  • Phone: 858-605-7960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG60559
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: