Healthcare Provider Details

I. General information

NPI: 1023113495
Provider Name (Legal Business Name): LYNNE L FAGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4108 MARYLAND AVE
BETHESDA MD
20816-2665
US

IV. Provider business mailing address

4108 MARYLAND AVE
BETHESDA MD
20816-2665
US

V. Phone/Fax

Practice location:
  • Phone: 301-320-2809
  • Fax:
Mailing address:
  • Phone: 301-320-2809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101039676
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO34054
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: