=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366657355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REGIS FRANCIS FALLON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14229 PALISADES DR
-----------------------------------------------------
City | POWAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92064-6461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-679-9201
-----------------------------------------------------
Fax | 858-486-1741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 500030
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92150-0030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-679-9201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | G60107
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------