Provider Demographics
NPI:1326537044
Name:FAN, JUSTON (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTON
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26520 CACTUS AVE.
Mailing Address - Street 2:RM. B2042
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555
Mailing Address - Country:US
Mailing Address - Phone:951-486-4698
Mailing Address - Fax:951-486-4106
Practice Address - Street 1:7200 CAMBRIDGE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-986-7396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX764034207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program