=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316167877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL H FAGERSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12264 EL CAMINO REAL SUITE 102
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-523-9700
-----------------------------------------------------
Fax | 858-523-9711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 OPAL ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-1831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-273-0911
-----------------------------------------------------
Fax | 858-273-0911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085B0100X
-----------------------------------------------------
Taxonomy Name | Body Imaging Physician
-----------------------------------------------------
License Number | G86628
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | G86628
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------