Provider Demographics
NPI:1982711206
Name:ROBERT S. P. FAN, MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT S. P. FAN, MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SIMON PETER
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-966-6085
Mailing Address - Street 1:1532 STATE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-2554
Mailing Address - Country:US
Mailing Address - Phone:805-966-6085
Mailing Address - Fax:805-966-6086
Practice Address - Street 1:1532 STATE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-2554
Practice Address - Country:US
Practice Address - Phone:805-966-6085
Practice Address - Fax:805-966-6086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG810210207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G810210Medicaid
W18403Medicare ID - Type Unspecified
CAE77977Medicare UPIN