Healthcare Provider Details

I. General information

NPI: 1982649018
Provider Name (Legal Business Name): LEE O FAGRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 20TH ST NW
WAVERLY IA
50677-2017
US

IV. Provider business mailing address

2101 KIMBALL AVE LL14
WATERLOO IA
50702-5063
US

V. Phone/Fax

Practice location:
  • Phone: 319-352-9500
  • Fax: 319-352-9509
Mailing address:
  • Phone: 319-272-1590
  • Fax: 319-272-1535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24990
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: