Provider Demographics
NPI:1083796726
Name:MICHAEL M. FANOUS, D.P.M., INC.
Entity Type:Organization
Organization Name:MICHAEL M. FANOUS, D.P.M., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FANOUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-951-1238
Mailing Address - Street 1:2834 HAMNER AVE
Mailing Address - Street 2:# 113
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-1929
Mailing Address - Country:US
Mailing Address - Phone:760-951-1238
Mailing Address - Fax:
Practice Address - Street 1:15366 11TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3726
Practice Address - Country:US
Practice Address - Phone:760-951-1238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3544213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02340ZMedicare ID - Type UnspecifiedMEDICARE #
CAT82756Medicare UPIN
CA6034990001Medicare NSC