Healthcare Provider Details

I. General information

NPI: 1255335154
Provider Name (Legal Business Name): PHILIP J. FAGAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14642 NEWPORT AVE STE 101
TUSTIN CA
92780-6058
US

IV. Provider business mailing address

2550 N HOLLYWOOD WAY STE 304
BURBANK CA
91505-5028
US

V. Phone/Fax

Practice location:
  • Phone: 714-581-6470
  • Fax: 714-581-6492
Mailing address:
  • Phone: 747-283-1809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC32505
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC32505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: