Provider Demographics
NPI:1083771398
Name:PHELAN, PATRICK E (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:E
Last Name:PHELAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11175 CAMPUS ST # A-1111
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1700
Mailing Address - Country:US
Mailing Address - Phone:909-558-8142
Mailing Address - Fax:
Practice Address - Street 1:82934 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-4308
Practice Address - Country:US
Practice Address - Phone:442-666-5076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-095191208000000X
GA86455208000000X
CAC173151208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095191 1Medicaid
G60898Medicare UPIN
IL036095191 1Medicaid