Healthcare Provider Details

I. General information

NPI: 1811095045
Provider Name (Legal Business Name): JEFFREY JAY FAGERLAND D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 LAUREL ST STE 1100
DES MOINES IA
50314-3044
US

IV. Provider business mailing address

330 LAUREL ST STE 1100
DES MOINES IA
50314-3044
US

V. Phone/Fax

Practice location:
  • Phone: 515-288-3287
  • Fax:
Mailing address:
  • Phone: 515-288-3287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02469
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: