Healthcare Provider Details

I. General information

NPI: 1457602419
Provider Name (Legal Business Name): BRUCE GARY FAGEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2012
Last Update Date: 09/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N CRESCENT DR SUITE 360
BEVERLY HILLS CA
90210-5408
US

IV. Provider business mailing address

100 N CRESCENT DR SUITE 360
BEVERLY HILLS CA
90210-5408
US

V. Phone/Fax

Practice location:
  • Phone: 310-281-8700
  • Fax: 310-281-5656
Mailing address:
  • Phone: 310-281-8700
  • Fax: 310-281-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG31252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: