Provider Demographics
NPI:1174721856
Name:FANKUSHEN, DAVID S (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:FANKUSHEN
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 1:16 RITTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3323
Mailing Address - Country:US
Mailing Address - Phone:415-457-8182
Mailing Address - Fax:415-457-3490
Practice Address - Street 1:12 RITTER ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94912
Practice Address - Country:US
Practice Address - Phone:415-457-8182
Practice Address - Fax:415-457-3490
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGFE10777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine