Provider Demographics
NPI:1558583369
Name:FANGONIL, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:FANGONIL
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 1:1160 VARNUM ST NE
Mailing Address - Street 2:SUITE 212 DEPAUL PROF BLDG
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2107
Mailing Address - Country:US
Mailing Address - Phone:202-529-3400
Mailing Address - Fax:202-832-8007
Practice Address - Street 1:1160 VARNUM ST NE
Practice Address - Street 2:SUITE 212 DEPAUL PROF BLDG
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2107
Practice Address - Country:US
Practice Address - Phone:202-529-3400
Practice Address - Fax:202-832-8007
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD5342208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0250OtherCAREFIRST OF DC
DC021223800Medicaid
DC341507534AOtherRAILROAD MEDICARE
DC341507534AOtherRAILROAD MEDICARE
DCB93738Medicare UPIN