Provider Demographics
NPI:1255335154
Name:FAGAN, PHILIP J JR (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:J
Last Name:FAGAN
Suffix:JR
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 1:2550 N HOLLYWOOD WAY STE 304
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-5028
Mailing Address - Country:US
Mailing Address - Phone:747-283-1809
Mailing Address - Fax:
Practice Address - Street 1:14642 NEWPORT AVE STE 101
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6058
Practice Address - Country:US
Practice Address - Phone:714-581-6470
Practice Address - Fax:714-581-6492
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32505207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C325050OtherBLUE SHIELD
CA00C325050Medicaid
CA00C325050OtherCALOPTIMA
CA930085818OtherRAILROAD MEDICARE
CAC32505OtherBLUE CROSS
CAC32505OtherBLUE CROSS
CA00C325050OtherCALOPTIMA
CAA34963Medicare UPIN