Healthcare Provider Details

I. General information

NPI: 1538148259
Provider Name (Legal Business Name): JULIAN CLAUS FAGERLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 RIVERBEND DR
CHARLOTTESVILLE VA
22911-8607
US

IV. Provider business mailing address

155 RIVERBEND DR
CHARLOTTESVILLE VA
22911-8607
US

V. Phone/Fax

Practice location:
  • Phone: 434-295-0184
  • Fax: 434-295-2463
Mailing address:
  • Phone: 434-295-0184
  • Fax: 434-295-2463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101225461
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: