Healthcare Provider Details

I. General information

NPI: 1194939421
Provider Name (Legal Business Name): JOHN MCLAIN FAGGARD III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 HIGHWAY 2
SANDPOINT ID
83864-1702
US

IV. Provider business mailing address

1005 HIGHWAY 2
SANDPOINT ID
83864-1702
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-5916
  • Fax: 208-255-2066
Mailing address:
  • Phone: 208-265-5916
  • Fax: 208-255-2066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM6916
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: