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General NPI Number Information
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NPI Number | 1083796726
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Entity Type | Organization
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Legal Business Name | MICHAEL M. FANOUS, D.P.M., INC.
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 07/31/2008
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Provider Practice Location Address
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Address Line | 15366 11TH ST SUITE D
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City | VICTORVILLE
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State | CA
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Zip | 92395-3726
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Country | US
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Telephone | 760-951-1238
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Fax |
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Provider Business Mailing Address
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Address Line | 2834 HAMNER AVE # 113
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City | NORCO
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State | CA
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Zip | 92860-1929
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Country | US
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Telephone | 760-951-1238
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL M. FANOUS
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Credential | D.P.M.
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Telephone | 760-951-1238
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | E3544
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License Number State | CA
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