Provider Demographics
NPI:1134151194
Name:FENNAR, TAD (DPM)
Entity type:Individual
Prefix:
First Name:TAD
Middle Name:
Last Name:FENNAR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W 6TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3531
Mailing Address - Country:US
Mailing Address - Phone:310-831-0728
Mailing Address - Fax:310-831-8564
Practice Address - Street 1:1300 W 6TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3531
Practice Address - Country:US
Practice Address - Phone:310-831-0728
Practice Address - Fax:310-831-8564
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4107213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41070Medicaid
CA000E41070Medicaid
CAU72683Medicare UPIN