Healthcare Provider Details

I. General information

NPI: 1538184791
Provider Name (Legal Business Name): MATTHEW J FAGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 05/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4375 OGLETOWN STANTON ROAD SUITE 1208
NEWARK DE
19713-2089
US

IV. Provider business mailing address

200 HYGEIA DR
NEWARK DE
19713-2049
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-4055
  • Fax: 302-623-4056
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD429235
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD429235
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberC10011078
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberC1-0011078
License Number StateDE
# 5
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberMD429235
License Number StatePA
# 6
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberC10011078
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: