Provider Demographics
NPI:1619072600
Name:FANOUS, BASEM (MD)
Entity Type:Individual
Prefix:
First Name:BASEM
Middle Name:
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 1:14124 FOOTHILL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342
Mailing Address - Country:US
Mailing Address - Phone:818-367-1012
Mailing Address - Fax:818-367-7570
Practice Address - Street 1:14124 FOOTHILL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342
Practice Address - Country:US
Practice Address - Phone:818-367-1012
Practice Address - Fax:818-367-7570
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53406207R00000X
CAA053406207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A534060Medicaid
CAA053406Medicaid
CAWA53406AMedicare ID - Type Unspecified
G27341Medicare UPIN
CAA053406Medicaid