Provider Demographics
NPI:1720189012
Name:FAGAN, ROGER (AUD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:FAGAN
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:ROGER
Other - Last Name:FAGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AUD
Mailing Address - Street 1:985 FOREST AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-797-8738
Mailing Address - Fax:207-797-8650
Practice Address - Street 1:985 FOREST AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-797-8738
Practice Address - Fax:207-797-8650
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDL95237600000X
MEAP25237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME709212Medicare ID - Type Unspecified