Provider Demographics
NPI:1356084487
Name:FAGAN, AVICHAI
Entity Type:Individual
Prefix:MR
First Name:AVICHAI
Middle Name:
Last Name:FAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8506 REBECCA LAUREN CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-2285
Mailing Address - Country:US
Mailing Address - Phone:443-630-6971
Mailing Address - Fax:
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2510
Practice Address - Country:US
Practice Address - Phone:786-910-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-17
Last Update Date:2022-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program