Provider Demographics
NPI:1629343462
Name:FEJERANG, JAMES DOUGLAS (IDC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DOUGLAS
Last Name:FEJERANG
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45099 TIOGA ST
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-1345
Mailing Address - Country:US
Mailing Address - Phone:951-972-2214
Mailing Address - Fax:
Practice Address - Street 1:45099 TIOGA ST
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-1345
Practice Address - Country:US
Practice Address - Phone:951-972-2214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman