MEDICARE: DR. GEORGE Z. FADDA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	A44918	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	WA44918D	OTHER	CA	SO. CALIFORNIA PTAN
3	CA122838	OTHER	CA	NO. CALIFORNIA PTAN

General Provider Information

NPI Number	:	1619972247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE Z. FADDA M.D.

Provider Business Mailing Address
First Line	:	4225 EXECUTIVE SQ STE 450
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92037-8411
Country	:	US
Telephone Number	:	858-810-0000
Fax Number	:	858-268-1911

Provider Business Practice Location Address
First Line	:	8851 CENTER DR
Second Line	:	STE 505
City	:	LA MESA
State	:	CA
Zip	:	91942-3017
Country	:	US
Telephone Number	:	619-461-3880
Fax Number	:	619-461-3895

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	01/26/2021

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