Healthcare Provider Details

I. General information

NPI: 1104812171
Provider Name (Legal Business Name): LEONARD SIMON FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10222 74TH STREET SUITE 200
KENOSHA WI
53142-6800
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 262-697-9200
  • Fax: 262-697-9206
Mailing address:
  • Phone: 414-389-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number46372-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number46372
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME157114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: