Provider Demographics
NPI:1649367475
Name:FASSETT, RICHARD L (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:FASSETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4116 W. PT. LOMA BLVD.
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110
Mailing Address - Country:US
Mailing Address - Phone:619-225-1212
Mailing Address - Fax:619-225-1726
Practice Address - Street 1:4116 W. PT. LOMA BLVD.
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110
Practice Address - Country:US
Practice Address - Phone:619-225-1212
Practice Address - Fax:619-225-1726
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30057207Q00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34109Medicare UPIN
CAWC30057AMedicare PIN