Provider Demographics
NPI:1326462631
Name:EL CAPITAN WOUND & DIABETIC CENTER INC
Entity Type:Organization
Organization Name:EL CAPITAN WOUND & DIABETIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-493-5484
Mailing Address - Street 1:4747 N 1ST ST STE 134
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0589
Mailing Address - Country:US
Mailing Address - Phone:559-493-5484
Mailing Address - Fax:559-493-5751
Practice Address - Street 1:4747 N 1ST ST STE 134
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726
Practice Address - Country:US
Practice Address - Phone:559-493-5484
Practice Address - Fax:559-493-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64927207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABC621AMedicare PIN