Provider Demographics
NPI:1134130990
Name:FENTON, PAMELA RUTH (MD)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:RUTH
Last Name:FENTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8737 BEVERLY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-1828
Mailing Address - Country:US
Mailing Address - Phone:310-854-4495
Mailing Address - Fax:310-854-1035
Practice Address - Street 1:8737 BEVERLY BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1828
Practice Address - Country:US
Practice Address - Phone:310-854-4495
Practice Address - Fax:310-854-1035
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38076174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91962Medicare UPIN