Healthcare Provider Details

I. General information

NPI: 1720220460
Provider Name (Legal Business Name): COLBY FAGIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2009
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 BROOKDALE DR
STATESVILLE NC
28677-3451
US

IV. Provider business mailing address

633 BROOKDALE DRIVE SUITE 300
STATESVILLE NC
28677-3403
US

V. Phone/Fax

Practice location:
  • Phone: 704-873-3250
  • Fax:
Mailing address:
  • Phone: 704-873-3250
  • Fax: 704-873-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2015-01496
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: