Healthcare Provider Details

I. General information

NPI: 1912041302
Provider Name (Legal Business Name): DAVID MICHAEL FAGAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N FEDERAL HWY
FORT LAUDERDALE FL
33304-2706
US

IV. Provider business mailing address

3000 NE 5TH TER APT 302A
WILTON MANORS FL
33334-2059
US

V. Phone/Fax

Practice location:
  • Phone: 954-779-1382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3856
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4409
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: