Provider Demographics
NPI:1235144395
Name:FAGERBERG, MARCIA D (MD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:D
Last Name:FAGERBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:6835 AUSTIN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3166
Practice Address - Country:US
Practice Address - Phone:512-346-6611
Practice Address - Fax:512-231-5201
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148825601Medicaid
TX148825602Medicaid
TX110232507Medicare PIN
TX148825601Medicaid
TX8K3524Medicare PIN