Provider Demographics
NPI:1679688766
Name:FAGAN, GARY DON (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DON
Last Name:FAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:751 HEBRON PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-5002
Mailing Address - Country:US
Mailing Address - Phone:972-459-2386
Mailing Address - Fax:972-459-2392
Practice Address - Street 1:751 HEBRON PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-5002
Practice Address - Country:US
Practice Address - Phone:972-459-2386
Practice Address - Fax:972-459-2392
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0014HUOtherBCBS
TX612968Medicare PIN
TX0014HUOtherBCBS