Healthcare Provider Details

I. General information

NPI: 1104261726
Provider Name (Legal Business Name): MARIE LOUISE FAGAN IDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 32ND ST APT 8
SAN DIEGO CA
92104-2080
US

IV. Provider business mailing address

4077 32ND ST APT 8
SAN DIEGO CA
92104-2080
US

V. Phone/Fax

Practice location:
  • Phone: 678-764-4067
  • Fax:
Mailing address:
  • Phone: 678-764-4067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: