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NPI Code Detail

MEDICARE: JOHN A FAGAN MD FAMILY PRACTICE INC

MEDICARE: JOHN A FAGAN MD FAMILY PRACTICE INC
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
1261QP2300XPrimary Care Clinic/CenterG060968CA

General Provider Information

NPI Number : 1417130881
Entity Type Code : Organization
Provider Name (Legal Business Name) : JOHN A FAGAN MD FAMILY PRACTICE INC
Provider Business Mailing Address
First Line : 10787 LAUREL ST
Second Line :
City : RANCHO CUCAMONGA
State : CA
Zip : 91730-3828
Country : US
Telephone Number : 909-982-7741
Fax Number : 909-931-9568
Provider Business Practice Location Address
First Line : 10787 LAUREL ST
Second Line :
City : RANCHO CUCAMONGA
State : CA
Zip : 91730-3828
Country : US
Telephone Number : 909-982-7741
Fax Number : 909-931-9568
Authorized Official
Title or Position : OWNER
Name : DR. JOHN ANDREW FAGAN
Credential : M.D.
Telephone Number : 909-982-7741
Provider Enumeration Date : 12/08/2007
Last Update Date : 02/04/2013

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