Provider Demographics
NPI:1689948234
Name:LAURENCE M FAKINOS, MD INC
Entity Type:Organization
Organization Name:LAURENCE M FAKINOS, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAKINOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-364-3050
Mailing Address - Street 1:27800 MEDICAL CENTER RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6410
Mailing Address - Country:US
Mailing Address - Phone:949-364-3050
Mailing Address - Fax:949-364-2135
Practice Address - Street 1:27800 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 260
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6410
Practice Address - Country:US
Practice Address - Phone:949-364-3050
Practice Address - Fax:949-364-2135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67377207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG6737700Medicaid
CAG6737700Medicaid