Provider Demographics
NPI:1710954854
Name:FOHAN, DAVID RANDAL (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RANDAL
Last Name:FOHAN
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 CASTLEWOODS DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1474
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 GAFFNEY RD #7440
Practice Address - Street 2:BASSETT ARMY COMMUNITY HOSPITAL
Practice Address - City:FT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-1474
Practice Address - Country:US
Practice Address - Phone:907-361-6028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0098041223G0001X
AL00015943207R00000X
GA034591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No1223G0001XDental ProvidersDentistGeneral Practice