Provider Demographics
NPI:1255370730
Name:FRAGOSO, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FRAGOSO
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 1:3322 US HIGHWAY 22 W
Mailing Address - Street 2:BUILDING 10, SUITE 1002
Mailing Address - City:BRANCHBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-3476
Mailing Address - Country:US
Mailing Address - Phone:908-725-5530
Mailing Address - Fax:908-253-6559
Practice Address - Street 1:1C NEW AMWELL RD
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-5006
Practice Address - Country:US
Practice Address - Phone:908-725-5530
Practice Address - Fax:908-874-3288
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04436600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1390309Medicaid
NJC61403Medicare UPIN