Healthcare Provider Details

I. General information

NPI: 1316126626
Provider Name (Legal Business Name): WALTER LEE FAGGETT II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4013 16TH ST NW NA
WASHINGTON DC
20011-7001
US

IV. Provider business mailing address

4013 16TH ST NW NA
WASHINGTON DC
20011-7001
US

V. Phone/Fax

Practice location:
  • Phone: 202-723-3100
  • Fax: 202-442-4790
Mailing address:
  • Phone: 202-723-3100
  • Fax: 202-442-4790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number5270
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number5270
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: