Basic Information
| Provider Information | |||||||||
| NPI: | 1346477585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITO | ||||||||
| FirstName: | DENNIS ALLEN | ||||||||
| MiddleName: | MINAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 TARMAN DR | ||||||||
| Address2: | |||||||||
| City: | CLOVERDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954253932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078944229 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6 TARMAN DR | ||||||||
| Address2: | |||||||||
| City: | CLOVERDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954253932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078944229 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2009 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25193 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200244560A | 05 | OK | MEDICAID |