Provider Demographics
NPI:1366657355
Name:FALLON, REGIS FRANCIS (MD)
Entity Type:Individual
Prefix:
First Name:REGIS
Middle Name:FRANCIS
Last Name:FALLON
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:PO BOX 500030
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92150-0030
Mailing Address - Country:US
Mailing Address - Phone:858-679-9201
Mailing Address - Fax:
Practice Address - Street 1:14229 PALISADES DR
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-6461
Practice Address - Country:US
Practice Address - Phone:858-679-9201
Practice Address - Fax:858-486-1741
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60107207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G601070OtherMEDI-CAL
CAG60107OtherMEDICAL LICENSE CA
CAG60107Medicare ID - Type Unspecified
CAG60107OtherMEDICAL LICENSE CA