Healthcare Provider Details

I. General information

NPI: 1881742203
Provider Name (Legal Business Name): ROBERT ANDREW FAGUET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 WILSHIRE BLVD SUITE 304
SANTA MONICA CA
90403-2344
US

IV. Provider business mailing address

3201 WILSHIRE BLVD SUITE 304
SANTA MONICA CA
90403-2344
US

V. Phone/Fax

Practice location:
  • Phone: 310-477-9833
  • Fax: 310-264-5931
Mailing address:
  • Phone: 310-477-9833
  • Fax: 310-264-5931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberG20685
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: