Provider Demographics
NPI:1164418257
Name:KAGAN, DONALD (PA)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:KAGAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BROADWAY STE 2
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2370
Mailing Address - Country:US
Mailing Address - Phone:203-234-6500
Mailing Address - Fax:203-234-6503
Practice Address - Street 1:2 BROADWAY STE 2
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473
Practice Address - Country:US
Practice Address - Phone:203-234-6500
Practice Address - Fax:203-234-6503
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000919363A00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP00441644OtherRAILROADMEDICARE
CT091900OtherCONNECTICARE
CT290000919CT06OtherANTHEM BCBS
CTP00441644OtherRAILROADMEDICARE
CT290000919CT06OtherANTHEM BCBS
CTP00441644OtherRAILROADMEDICARE