Provider Demographics
NPI:1871816066
Name:TROY V. FENNELL M.D.
Entity Type:Organization
Organization Name:TROY V. FENNELL M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:V
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-786-5360
Mailing Address - Street 1:13521 SHERMAN WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2894
Mailing Address - Country:US
Mailing Address - Phone:818-786-5360
Mailing Address - Fax:818-786-5670
Practice Address - Street 1:13521 SHERMAN WAY
Practice Address - Street 2:SUITE D
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2894
Practice Address - Country:US
Practice Address - Phone:818-786-5360
Practice Address - Fax:818-786-5670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100492207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty