Provider Demographics
NPI:1740205590
Name:FAGAN, PETER G (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:G
Last Name:FAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:DE LEON
Mailing Address - State:TX
Mailing Address - Zip Code:76444-0488
Mailing Address - Country:US
Mailing Address - Phone:254-893-4099
Mailing Address - Fax:
Practice Address - Street 1:10201 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:COMANCHE
Practice Address - State:TX
Practice Address - Zip Code:76442-4462
Practice Address - Country:US
Practice Address - Phone:254-879-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A5652OtherMC GRP
TXC15552Medicare UPIN
TX0A5652OtherMC GRP