Provider Demographics
NPI:1407814486
Name:FAGAN, ROYCE MILTON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROYCE
Middle Name:MILTON
Last Name:FAGAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10 MAGGIES CT
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-4730
Mailing Address - Country:US
Mailing Address - Phone:443-744-8106
Mailing Address - Fax:410-581-1662
Practice Address - Street 1:9419 COMMON BROOK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-7536
Practice Address - Country:US
Practice Address - Phone:410-581-1662
Practice Address - Fax:410-581-1120
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC55132207R00000X, 208M00000X
MDD055625207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400588100Medicaid
MD400588100Medicaid
MD773M340FMedicare ID - Type Unspecified