Healthcare Provider Details

I. General information

NPI: 1225212566
Provider Name (Legal Business Name): TROY FENNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27574 COMMERCE CENTER DR SUITE 232
TEMECULA CA
92590-2500
US

IV. Provider business mailing address

27574 COMMERCE CENTER DR SUITE 232
TEMECULA CA
92590-2500
US

V. Phone/Fax

Practice location:
  • Phone: 951-695-9648
  • Fax: 951-695-3949
Mailing address:
  • Phone: 951-695-9648
  • Fax: 951-695-3949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA100492
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberA100492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: