Provider Demographics
NPI:1841220423
Name:FAGAN, DAVID S (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:FAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 BOULDER POINT DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-3170
Mailing Address - Country:US
Mailing Address - Phone:603-536-4000
Mailing Address - Fax:603-536-4001
Practice Address - Street 1:101 BOULDER POINT DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3170
Practice Address - Country:US
Practice Address - Phone:603-536-4000
Practice Address - Fax:603-536-4001
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NHNH8707207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT11P018OtherMVP
VTFAGA18669OtherVT BC BS
PA137310OtherCIGNA SCRANTON
NHANTHEMOtherBLUE CROSS BLUE SHIELD
110095743OtherRRMCR
VT2165Medicaid
NH80002165Medicaid
110095743OtherRRMCR
NHF26771Medicare UPIN
303809Medicare ID - Type Unspecified