Provider Demographics
NPI:1821110396
Name:FAGERSON, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:FAGERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 W COLONIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067-1207
Mailing Address - Country:US
Mailing Address - Phone:847-358-1588
Mailing Address - Fax:847-358-1542
Practice Address - Street 1:1644 W COLONIAL PKWY
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:IL
Practice Address - Zip Code:60067-1207
Practice Address - Country:US
Practice Address - Phone:847-358-1588
Practice Address - Fax:847-358-1542
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360857412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF69378Medicare UPIN
209958Medicare PIN