Healthcare Provider Details

I. General information

NPI: 1639412091
Provider Name (Legal Business Name): PEOLIA KANSAS FONSWORTH III M.D., M.B.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST
TORRANCE CA
90502-2004
US

IV. Provider business mailing address

1000 W CARSON ST
TORRANCE CA
90502-2004
US

V. Phone/Fax

Practice location:
  • Phone: 310-222-2345
  • Fax:
Mailing address:
  • Phone: 415-240-5467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA132680
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 Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA132680
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: