Provider Demographics
NPI:1477584092
Name:FAGERHOLM, ROBERT JAMES (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:FAGERHOLM
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 1:24151 HAZEL RD
Mailing Address - Street 2:
Mailing Address - City:ELKPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52044-8320
Mailing Address - Country:US
Mailing Address - Phone:563-245-1547
Mailing Address - Fax:
Practice Address - Street 1:1000 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2800
Practice Address - Country:US
Practice Address - Phone:641-422-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAG39385Medicare UPIN