Healthcare Provider Details

I. General information

NPI: 1194702761
Provider Name (Legal Business Name): LEONARD FAGEN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 WOODLAND WAY
QUOGUE NY
11959-1571
US

IV. Provider business mailing address

PO BOX 1571 8 WOODLAND WAY
QUOGUE NY
11959-1571
US

V. Phone/Fax

Practice location:
  • Phone: 631-653-0077
  • Fax: 631-653-3388
Mailing address:
  • Phone: 631-653-0077
  • Fax: 631-653-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2044
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: