Healthcare Provider Details

I. General information

NPI: 1972520054
Provider Name (Legal Business Name): CRAYTON A FARGASON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 7TH AVE S
BIRMINGHAM AL
35233-1711
US

IV. Provider business mailing address

703 VOLKER HALL
BIRMINGHAM AL
35294-0001
US

V. Phone/Fax

Practice location:
  • Phone: 205-939-9585
  • Fax: 205-975-6503
Mailing address:
  • Phone: 205-934-3795
  • Fax: 205-975-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15776
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: