Provider Demographics
NPI:1376649657
Name:FAGEN, SHELDON G (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELDON
Middle Name:G
Last Name:FAGEN
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 1:994 W JERICHO TPKE STE 201
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3234
Mailing Address - Country:US
Mailing Address - Phone:631-864-4499
Mailing Address - Fax:631-864-6023
Practice Address - Street 1:994 W JERICHO TPKE STE 201
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3234
Practice Address - Country:US
Practice Address - Phone:631-864-4499
Practice Address - Fax:631-864-6023
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096746207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00373900Medicaid
NY916551Medicare ID - Type Unspecified
NY00373900Medicaid