Healthcare Provider Details

I. General information

NPI: 1578983193
Provider Name (Legal Business Name): CRYSTAL ELIZABETH FANCHER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 SANTA MONICA BLVD
SANTA MONICA CA
90404-2312
US

IV. Provider business mailing address

1520 SAN PABLO ST STE 4300
LOS ANGELES CA
90033-5330
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7096
  • Fax: 310-582-7236
Mailing address:
  • Phone: 323-442-8168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA162160
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA162160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: