Provider Demographics
NPI:1225212566
Name:FENNELL, TROY (MD)
Entity Type:Individual
Prefix:DR
First Name:TROY
Middle Name:
Last Name:FENNELL
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 1:27574 COMMERCE CENTER DR
Mailing Address - Street 2:SUITE 232
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2500
Mailing Address - Country:US
Mailing Address - Phone:951-695-9648
Mailing Address - Fax:951-695-3949
Practice Address - Street 1:27574 COMMERCE CENTER DR
Practice Address - Street 2:SUITE 232
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2500
Practice Address - Country:US
Practice Address - Phone:951-695-9648
Practice Address - Fax:951-695-3949
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100492207Q00000X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA100492OtherSTATE LICENSE
CAA100492Medicare PIN