Provider Demographics
NPI:1710153069
Name:FAGAN, FREDERICK JOHN (OD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOHN
Last Name:FAGAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 OXFORD CT
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-5251
Mailing Address - Country:US
Mailing Address - Phone:630-629-1711
Mailing Address - Fax:
Practice Address - Street 1:141 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2322
Practice Address - Country:US
Practice Address - Phone:708-492-1425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006959152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist