Healthcare Provider Details

I. General information

NPI: 1255324042
Provider Name (Legal Business Name): JOHN EDWARD FAGAN JR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20231 W VALLEY BLVD SUITE G
TEHACHAPI CA
93561-6748
US

IV. Provider business mailing address

20231 W VALLEY BLVD SUITE G
TEHACHAPI CA
93561-6748
US

V. Phone/Fax

Practice location:
  • Phone: 661-822-1212
  • Fax: 661-822-3296
Mailing address:
  • Phone: 661-822-1212
  • Fax: 661-822-3296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7946T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1688
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: