Healthcare Provider Details

I. General information

NPI: 1740308550
Provider Name (Legal Business Name): BRIAN T FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC 5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5855
  • Fax: 858-571-7903
Mailing address:
  • Phone: 858-309-6300
  • Fax: 858-309-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA82153
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: