Provider Demographics
NPI:1407954654
Name:FENISON, ANTHONY TYRON (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:TYRON
Last Name:FENISON
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 1:23100 EUCALYPTUS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553
Mailing Address - Country:US
Mailing Address - Phone:951-924-4700
Mailing Address - Fax:951-924-1320
Practice Address - Street 1:23100 EUCALYPTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553
Practice Address - Country:US
Practice Address - Phone:951-924-4700
Practice Address - Fax:951-924-1320
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73330207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G19547Medicare UPIN
CADN614Medicare PIN