Healthcare Provider Details

I. General information

NPI: 1184799058
Provider Name (Legal Business Name): JERRY S FAGELMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39400 GARFIELD RD SUITE 103
CLINTON TOWNSHIP MI
48038-4096
US

IV. Provider business mailing address

39400 GARFIELD RD SUITE 103
CLINTON TOWNSHIP MI
48038-4096
US

V. Phone/Fax

Practice location:
  • Phone: 586-286-6550
  • Fax: 586-286-1843
Mailing address:
  • Phone: 586-286-6550
  • Fax: 586-286-6550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberJF025417
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: