Provider Demographics
NPI:1235127481
Name:FAGG, THOMAS W (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:FAGG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:IA
Mailing Address - Zip Code:50129
Mailing Address - Country:US
Mailing Address - Phone:515-386-4192
Mailing Address - Fax:515-386-3448
Practice Address - Street 1:1002 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129
Practice Address - Country:US
Practice Address - Phone:515-386-4192
Practice Address - Fax:515-386-3448
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0074856Medicaid
IAI21882Medicare PIN
IAE92191Medicare UPIN