Provider Demographics
NPI:1033227806
Name:FAGUNDES, HUMBERTO M (MD)
Entity Type:Individual
Prefix:
First Name:HUMBERTO
Middle Name:M
Last Name:FAGUNDES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:55 W PORT PLZ
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3109
Mailing Address - Country:US
Mailing Address - Phone:314-548-4772
Mailing Address - Fax:314-548-4748
Practice Address - Street 1:3015 N NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-996-5180
Practice Address - Fax:314-821-2180
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1001212085R0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
32286OtherBNDD
100121OtherMO LICENSE
33012444OtherCPIN
920004686OtherRRMEDICARE
207947516OtherMCAID
207947516OtherMCAID
BF3076127OtherDEA