Healthcare Provider Details

I. General information

NPI: 1356084487
Provider Name (Legal Business Name): MR. AVICHAI FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2022
Last Update Date: 04/17/2022
Certification Date: 04/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S ANDREWS AVE
FORT LAUDERDALE FL
33316-2510
US

IV. Provider business mailing address

8506 REBECCA LAUREN CT
BALTIMORE MD
21208-2285
US

V. Phone/Fax

Practice location:
  • Phone: 786-910-3801
  • Fax:
Mailing address:
  • Phone: 443-630-6971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: