Provider Demographics
NPI:1194798207
Name:MEDEIROS, FABIOLA (MD)
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2374 E PACIFICA PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO DOMINGUEZ
Mailing Address - State:CA
Mailing Address - Zip Code:90220-6214
Mailing Address - Country:US
Mailing Address - Phone:310-225-3221
Mailing Address - Fax:310-698-7040
Practice Address - Street 1:2374 E PACIFICA PL
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220
Practice Address - Country:US
Practice Address - Phone:310-225-3221
Practice Address - Fax:310-698-7040
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47986207ZP0102X
CAC54977207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN318039500Medicaid
MNP00415217OtherMEDICARE RAILROAD
MNP00415217OtherMEDICARE RAILROAD
I42571Medicare UPIN