Provider Demographics
NPI:1255324042
Name:FAGAN, JOHN EDWARD JR (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:FAGAN
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20231 W VALLEY BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-6748
Mailing Address - Country:US
Mailing Address - Phone:661-822-1212
Mailing Address - Fax:661-822-3296
Practice Address - Street 1:20231 W VALLEY BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-6748
Practice Address - Country:US
Practice Address - Phone:661-822-1212
Practice Address - Fax:661-822-3296
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7946T152W00000X
OR1688152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABL893Medicaid
CA1619129921OtherNPPES
CA1619129921OtherNPPES
CABL893Medicare PIN