Provider Demographics
NPI:1760644686
Name:LUIS A FIALLO MD PC
Entity Type:Organization
Organization Name:LUIS A FIALLO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FIALLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACP FCC
Authorized Official - Phone:619-421-4000
Mailing Address - Street 1:754 MEDICAL CENTER CT
Mailing Address - Street 2:100
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6655
Mailing Address - Country:US
Mailing Address - Phone:619-450-9960
Mailing Address - Fax:619-773-7956
Practice Address - Street 1:754 MEDICAL CENTER CT
Practice Address - Street 2:100
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6655
Practice Address - Country:US
Practice Address - Phone:619-421-4000
Practice Address - Fax:619-421-6395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C513090Medicaid
CA1407824600OtherNPI
CA00C513090Medicaid