Provider Demographics
NPI:1851404859
Name:FANGMAN, WILLIAM LEO (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LEO
Last Name:FANGMAN
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 1:1072 X RAY DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7498
Mailing Address - Country:US
Mailing Address - Phone:704-691-1074
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:959 COX RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3420
Practice Address - Country:US
Practice Address - Phone:704-866-7576
Practice Address - Fax:704-866-0106
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201075207N00000X
FLME100630207N00000X
NC2019-00293207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904546Medicaid
FL280314300Medicaid
FL280314300Medicaid
I60613Medicare UPIN
BF9759955OtherDEA
NC5904546Medicaid