Healthcare Provider Details

I. General information

NPI: 1316167877
Provider Name (Legal Business Name): DANIEL H FAGERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12264 EL CAMINO REAL SUITE 102
SAN DIEGO CA
92130-3058
US

IV. Provider business mailing address

1111 OPAL ST
SAN DIEGO CA
92109-1831
US

V. Phone/Fax

Practice location:
  • Phone: 858-523-9700
  • Fax: 858-523-9711
Mailing address:
  • Phone: 858-273-0911
  • Fax: 858-273-0911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberG86628
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG86628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: