Healthcare Provider Details

I. General information

NPI: 1952354763
Provider Name (Legal Business Name): DAVID B FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 270
SAINT LOUIS MO
63128-3201
US

IV. Provider business mailing address

12700 SOUTHFORK RD STE 270
SAINT LOUIS MO
63128-3201
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5284
  • Fax: 314-543-5276
Mailing address:
  • Phone: 314-543-5284
  • Fax: 314-543-5276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number104219
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: