Provider Demographics
NPI:1376518886
Name:FAGIN, GARY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:FAGIN
Suffix:
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 1:75 GATES ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-4606
Mailing Address - Country:US
Mailing Address - Phone:603-957-1379
Mailing Address - Fax:
Practice Address - Street 1:75 GATES ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4606
Practice Address - Country:US
Practice Address - Phone:603-957-1379
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHB85971Medicare UPIN