Provider Demographics
NPI:1689622177
Name:FABRIKANT, JERRY M (DPM)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:M
Last Name:FABRIKANT
Suffix:
Gender:M
Credentials:DPM
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BLDG 3 #353
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3007
Mailing Address - Country:US
Mailing Address - Phone:619-465-3443
Mailing Address - Fax:619-466-7311
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BLDG 3 # 353
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3007
Practice Address - Country:US
Practice Address - Phone:619-465-3443
Practice Address - Fax:619-466-7311
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2009-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA000E23120213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0367040001Medicare NSC