Provider Demographics
NPI:1982649018
Name:FAGRE, LEE O (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:O
Last Name:FAGRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:217 20TH ST NW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2017
Practice Address - Country:US
Practice Address - Phone:319-352-9500
Practice Address - Fax:319-352-9509
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA24990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3034843Medicaid
IA40011Medicare PIN
IA3034843Medicaid