Healthcare Provider Details

I. General information

NPI: 1558879437
Provider Name (Legal Business Name): ROBERT FAGGELLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2018
Last Update Date: 01/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 RIVERBANK PL
CARMICHAEL CA
95608-5233
US

IV. Provider business mailing address

16 RIVERBANK PL
CARMICHAEL CA
95608-5233
US

V. Phone/Fax

Practice location:
  • Phone: 916-979-9860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG5705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: