MEDICARE: DR. DAVID FAGAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	210189	NY

General Provider Information

NPI Number	:	1245233790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID FAGAN M.D.

Provider Business Mailing Address
First Line	:	180 W OLIVE ST
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-3314
Country	:	US
Telephone Number	:	516-705-5170
Fax Number	:	718-597-9500

Provider Business Practice Location Address
First Line	:	2016 BRONXDALE AVE
Second Line	:	STE 203
City	:	BRONX
State	:	NY
Zip	:	10462-3365
Country	:	US
Telephone Number	:	718-597-0700
Fax Number	:	718-597-9500

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2005
Last Update Date	:	07/08/2007

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