Healthcare Provider Details

I. General information

NPI: 1639286263
Provider Name (Legal Business Name): FATMA HANEY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FATMA DENICHOLAS M.D

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WINTHROP RD
SAN MARINO CA
91108-1708
US

IV. Provider business mailing address

840 WINTHROP RD
SAN MARINO CA
91108-1708
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-2606
  • Fax: 575-622-6645
Mailing address:
  • Phone: 575-622-2606
  • Fax: 575-622-6645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2006-0086
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA063529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: