Healthcare Provider Details

I. General information

NPI: 1811564776
Provider Name (Legal Business Name): PATRICK TIMOTHY FUSUNYAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 GARNET AVE
SAN DIEGO CA
92109-3523
US

IV. Provider business mailing address

1945 GARNET AVE
SAN DIEGO CA
92109-3523
US

V. Phone/Fax

Practice location:
  • Phone: 858-224-7977
  • Fax: 858-224-7978
Mailing address:
  • Phone: 858-224-7977
  • Fax: 858-224-7978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A24331
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT020938
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: