Provider Demographics
NPI:1023075140
Name:FAGAN, ROY O III (MD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:O
Last Name:FAGAN
Suffix:III
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:PO BOX 2123
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323
Mailing Address - Country:US
Mailing Address - Phone:336-342-4448
Mailing Address - Fax:336-342-4499
Practice Address - Street 1:419 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320
Practice Address - Country:US
Practice Address - Phone:336-342-4448
Practice Address - Fax:336-342-4499
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC130425207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7931038Medicaid
NC7931038Medicaid
2348216Medicare ID - Type Unspecified