Provider Demographics
NPI:1770758310
Name:FAYNER, SHELDON (MD)
Entity type:Individual
Prefix:
First Name:SHELDON
Middle Name:
Last Name:FAYNER
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 1:3356 W BALL RD
Mailing Address - Street 2:STE 206
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3702
Mailing Address - Country:US
Mailing Address - Phone:714-827-8890
Mailing Address - Fax:714-827-8905
Practice Address - Street 1:3356 W BALL RD
Practice Address - Street 2:STE 206
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3702
Practice Address - Country:US
Practice Address - Phone:714-827-8890
Practice Address - Fax:714-827-8905
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34800207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G348000OtherBLUE SHIELD
CA00G348000Medicaid
CAG34800AMedicare PIN
CAA0272Medicare PIN
CA00G348000Medicaid