Provider Demographics
NPI:1760482400
Name:FAGEN, BRUCE D (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:D
Last Name:FAGEN
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 1074
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34697-1074
Mailing Address - Country:US
Mailing Address - Phone:727-734-6516
Mailing Address - Fax:727-734-4516
Practice Address - Street 1:601 MAIN ST
Practice Address - Street 2:STE 205
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-5848
Practice Address - Country:US
Practice Address - Phone:727-734-6516
Practice Address - Fax:727-734-4516
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72320207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260527900Medicaid
FL45040OtherBCBS OF FL
FL260527900Medicaid
FL45040ZMedicare ID - Type Unspecified