Healthcare Provider Details

I. General information

NPI: 1033227806
Provider Name (Legal Business Name): HUMBERTO M FAGUNDES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N NEW BALLAS RD
ST LOUIS MO
63131
US

IV. Provider business mailing address

55 W PORT PLZ SUITE 300
SAINT LOUIS MO
63146-3109
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5180
  • Fax: 314-821-2180
Mailing address:
  • Phone: 314-548-4772
  • Fax: 314-548-4748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number100121
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number100121
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: