Provider Demographics
NPI:1477892909
Name:FAGELMAN, FREDRIC IRA (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:IRA
Last Name:FAGELMAN
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 1:13 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1307
Mailing Address - Country:US
Mailing Address - Phone:518-792-6983
Mailing Address - Fax:
Practice Address - Street 1:13 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1307
Practice Address - Country:US
Practice Address - Phone:518-792-6983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122981-1207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery