Provider Demographics
NPI:1851578819
Name:JERRY M FABRIKANT DPM, INC
Entity Type:Organization
Organization Name:JERRY M FABRIKANT DPM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FABRIKANT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:619-465-3443
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BLDG 3 STE 353
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-465-3443
Mailing Address - Fax:619-466-7311
Practice Address - Street 1:5565 GROSSMONT CENTER DR STE 3
Practice Address - Street 2:STE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6124170001Medicare NSC
CA0367040001Medicare NSC