Healthcare Provider Details

I. General information

NPI: 1497752737
Provider Name (Legal Business Name): WARREN ROBERT FAGADAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6131 LUTHER LANE STE 216
DALLAS TX
75225-6298
US

IV. Provider business mailing address

6131 LUTHER LANE STE 216
DALLAS TX
75225-6298
US

V. Phone/Fax

Practice location:
  • Phone: 214-987-2020
  • Fax: 214-739-3725
Mailing address:
  • Phone: 214-987-2020
  • Fax: 214-739-3725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberF1536
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: