Provider Demographics
NPI:1801947312
Name:FALLON, SANDRA PHILOMENA (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:PHILOMENA
Last Name:FALLON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2020 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 580
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2023
Mailing Address - Country:US
Mailing Address - Phone:310-453-4455
Mailing Address - Fax:310-453-8833
Practice Address - Street 1:2020 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 580
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2023
Practice Address - Country:US
Practice Address - Phone:310-453-4455
Practice Address - Fax:310-453-8833
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46060207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46060OtherCA STATE LICENSE
CAWA46060EOtherPPIN
CAWA46060EOtherPPIN