Healthcare Provider Details

I. General information

NPI: 1891799367
Provider Name (Legal Business Name): RANDY SCOTT FAGIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11410 JOLLYVILLE RD STE 1101
AUSTIN TX
78759-4093
US

IV. Provider business mailing address

11410 JOLLYVILLE RD STE 1101
AUSTIN TX
78759-4093
US

V. Phone/Fax

Practice location:
  • Phone: 512-231-1444
  • Fax: 512-231-1470
Mailing address:
  • Phone: 512-231-1444
  • Fax: 512-231-1470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL4930
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: