Provider Demographics
NPI:1235634940
Name:FAGAN, PHILIP III (MD)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:
Last Name:FAGAN
Suffix:III
Gender:M
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:NAVAL MEDICAL CENTER SAN DIEGO 38400 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:412-951-9701
Mailing Address - Fax:
Practice Address - Street 1:2075 SAN JOAQUIN HILLS RD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-6505
Practice Address - Country:US
Practice Address - Phone:949-760-9222
Practice Address - Fax:949-579-2906
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA163621208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program