Healthcare Provider Details

I. General information

NPI: 1003970203
Provider Name (Legal Business Name): PETER G FAGAN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 HIGHWAY 16
COMANCHE TX
76442-4462
US

IV. Provider business mailing address

PO BOX 488
DE LEON TX
76444-0488
US

V. Phone/Fax

Practice location:
  • Phone: 254-879-4900
  • Fax: 254-879-4989
Mailing address:
  • Phone: 254-893-4099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC15552
License Number StateTX

VIII. Authorized Official

Name: PETER G FAGAN
Title or Position: SOLE PROPRIETOR
Credential: M.D.
Phone: 254-879-4910