MEDICARE: JEFFREY FARGASON

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	237700000X	Hearing Instrument Specialist	HADS000445	GA

General Provider Information

NPI Number	:	1508243817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY FARGASON

Provider Business Mailing Address
First Line	:	917 N INDIAN CREEK DR
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-2245
Country	:	US
Telephone Number	:	404-299-1141
Fax Number	:	404-299-8195

Provider Business Practice Location Address
First Line	:	917 N INDIAN CREEK DR
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-2245
Country	:	US
Telephone Number	:	404-299-1141
Fax Number	:	404-299-8195

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

Provider Enumeration Date	:	05/06/2015
Last Update Date	:	05/06/2015

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Directions to “ JEFFREY FARGASON ” Practice Location

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