Provider Demographics
NPI:1639115454
Name:FANOUS, D.P.M. , INC., MICHAEL M
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:FANOUS, D.P.M. , INC.
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2834 HAMNER AVE
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-1929
Mailing Address - Country:US
Mailing Address - Phone:760-951-1238
Mailing Address - Fax:760-951-1473
Practice Address - Street 1:15366 11TH ST STE D
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3726
Practice Address - Country:US
Practice Address - Phone:760-951-1238
Practice Address - Fax:760-951-1473
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3544213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ02340ZMedicare ID - Type Unspecified
CAT82756Medicare UPIN