Provider Demographics
NPI:1659495885
Name:FAGO, DAVID P (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:FAGO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 INDEPENDENCE AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-3918
Mailing Address - Country:US
Mailing Address - Phone:202-441-8823
Mailing Address - Fax:301-927-8052
Practice Address - Street 1:7307 BALTIMORE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-3231
Practice Address - Country:US
Practice Address - Phone:301-277-3250
Practice Address - Fax:301-927-8052
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01730103T00000X, 103TC2200X, 103TF0000X
DC1000523103T00000X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD591698Medicare ID - Type Unspecified