Healthcare Provider Details

I. General information

NPI: 1710153069
Provider Name (Legal Business Name): FREDERICK JOHN FAGAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W NORTH AVE
NORTHLAKE IL
60164-2322
US

IV. Provider business mailing address

1109 OXFORD CT
OAKBROOK TERRACE IL
60181-5251
US

V. Phone/Fax

Practice location:
  • Phone: 708-492-1425
  • Fax:
Mailing address:
  • Phone: 630-629-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046006959
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: