Provider Demographics
NPI:1457329716
Name:FANOUS, VADIM V (MD)
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:V
Last Name:FANOUS
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 1:3330 LOMITA BLVD
Mailing Address - Street 2:HEALTH CARE PARTNERS OFFICE
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5002
Mailing Address - Country:US
Mailing Address - Phone:310-784-8770
Mailing Address - Fax:
Practice Address - Street 1:3330 LOMITA BLVD
Practice Address - Street 2:HEALTH CARE PARTNERS OFFICE
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5002
Practice Address - Country:US
Practice Address - Phone:310-784-8770
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76985207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H94130Medicare UPIN