=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184625915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM FENERTY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2005
-----------------------------------------------------
Last Update Date | 11/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1514 VALLEY VISTA DR
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-449-4842
-----------------------------------------------------
Fax | 714-449-4816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 IMPERIAL HWY SUITE 730
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92835-1041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-449-4842
-----------------------------------------------------
Fax | 714-449-4816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 20A4089
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------