Healthcare Provider Details

I. General information

NPI: 1245233790
Provider Name (Legal Business Name): DAVID FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 BRONXDALE AVE STE 203
BRONX NY
10462-3365
US

IV. Provider business mailing address

180 W OLIVE ST
LONG BEACH NY
11561-3314
US

V. Phone/Fax

Practice location:
  • Phone: 718-597-0700
  • Fax: 718-597-9500
Mailing address:
  • Phone: 516-705-5170
  • Fax: 718-597-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number210189
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: