Provider Demographics
NPI:1376819011
Name:FOULKE, GARRETT EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:EDWIN
Last Name:FOULKE
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 1:773 ALTA VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-5102
Mailing Address - Country:US
Mailing Address - Phone:858-354-8686
Mailing Address - Fax:
Practice Address - Street 1:4370 LA JOLLA VILLAGE DR
Practice Address - Street 2:SUITE 700
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1249
Practice Address - Country:US
Practice Address - Phone:858-587-5318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39817207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA47976Medicare UPIN