Provider Demographics
NPI:1508837873
Name:FENTON, DREW EVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DREW
Middle Name:EVAN
Last Name:FENTON
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 1:691 IROLO ST APT 1706
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-4137
Mailing Address - Country:US
Mailing Address - Phone:213-247-4000
Mailing Address - Fax:800-884-7293
Practice Address - Street 1:1730 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 100, GROUND FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1019
Practice Address - Country:US
Practice Address - Phone:213-247-4000
Practice Address - Fax:800-884-7293
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G555000Medicaid
CA00G555000Medicaid
CAWG55500FMedicare PIN