Provider Demographics
NPI:1669476446
Name:FAGELMAN, DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:FAGELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 EAST MAIN ST.
Mailing Address - Street 2:NSLIJ- SOUTHSIDE HOSPITAL, DEPT. OF RADIOLOGY
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-968-3290
Mailing Address - Fax:631-968-7486
Practice Address - Street 1:301 EAST MAIN ST.
Practice Address - Street 2:NSLIJ- SOUTHSIDE HOSPITAL, DEPT. OF RADIOLOGY
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-968-3290
Practice Address - Fax:631-968-7486
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1421322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB12921Medicare UPIN
NY32A551Medicare ID - Type Unspecified