Provider Demographics
NPI:1326111261
Name:FUGATE, DAVID JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JAMES
Last Name:FUGATE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 HASLETT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8469
Mailing Address - Country:US
Mailing Address - Phone:517-347-8420
Mailing Address - Fax:517-347-8420
Practice Address - Street 1:1660 HASLETT RD
Practice Address - Street 2:SUITE 1
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-8469
Practice Address - Country:US
Practice Address - Phone:517-347-8420
Practice Address - Fax:517-347-8420
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006608103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP112677OtherVALUE OPTIONS
MION86340Medicare ID - Type Unspecified
MIP112677OtherVALUE OPTIONS