Provider Demographics
NPI:1750315958
Name:FAGEN, TIMOTHY D (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:FAGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 S GRAND BLVD STE M260
Mailing Address - Street 2:ST LOUIS UNIVERSITY GME
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-577-8782
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD STE M260
Practice Address - Street 2:ST LOUIS UNIVERSITY GME
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-577-8782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017047208D00000X
HIDOS 1120208D00000X
MO2010014000207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice