Healthcare Provider Details

I. General information

NPI: 1639507510
Provider Name (Legal Business Name): JONATHAN VAL C. FAGEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 HADDONFIELD BERLIN RD
VOORHEES NJ
08043-3714
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 856-679-0537
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH0080015
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB10210800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: