Provider Demographics
NPI:1003970203
Name:PETER G FAGAN MD PA
Entity Type:Organization
Organization Name:PETER G FAGAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:G
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-879-4910
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:DE LEON
Mailing Address - State:TX
Mailing Address - Zip Code:76444-0488
Mailing Address - Country:US
Mailing Address - Phone:254-893-4099
Mailing Address - Fax:
Practice Address - Street 1:10201 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:COMANCHE
Practice Address - State:TX
Practice Address - Zip Code:76442-4462
Practice Address - Country:US
Practice Address - Phone:254-879-4900
Practice Address - Fax:254-879-4989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC15552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8F23579OtherMC INDIVIDUAL
TXC15552Medicare UPIN
8F23579OtherMC INDIVIDUAL