Provider Demographics
NPI:1255417523
Name:FAGAN, MICHELE J (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:J
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:165 BENNETT AVE
Mailing Address - Street 2:APT. 4G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-4013
Mailing Address - Country:US
Mailing Address - Phone:718-920-5312
Mailing Address - Fax:718-798-6485
Practice Address - Street 1:MMC - PEDS. EMERGENCY MEDICINE
Practice Address - Street 2:111 EAST 210TH STREET
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-5312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2129082080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine