Healthcare Provider Details

I. General information

NPI: 1801827019
Provider Name (Legal Business Name): JOHN DAVID FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 HIGHWAY 61 N
VICKSBURG MS
39183-8246
US

IV. Provider business mailing address

2080 SOUTH FRONTAGE RD SUITE 100
VICKSBURG MS
39180
US

V. Phone/Fax

Practice location:
  • Phone: 601-883-5940
  • Fax:
Mailing address:
  • Phone: 601-262-1000
  • Fax: 601-262-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number12624
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: