Provider Demographics
NPI:1780685164
Name:FRAGATOS, PETER D (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:FRAGATOS
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 1:950 WINDHAM CT
Mailing Address - Street 2:STE 1
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5083
Mailing Address - Country:US
Mailing Address - Phone:330-965-1847
Mailing Address - Fax:330-965-1847
Practice Address - Street 1:950 WINDHAM CT
Practice Address - Street 2:SUITE 1
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-5083
Practice Address - Country:US
Practice Address - Phone:330-965-1847
Practice Address - Fax:330-965-1857
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083165207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2472748Medicaid
OHB45445Medicare UPIN
OH9357941Medicare PIN
OH4172231Medicare PIN