Provider Demographics
NPI:1295707156
Name:FAGAN, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BANK ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3661
Mailing Address - Country:US
Mailing Address - Phone:908-376-6550
Mailing Address - Fax:
Practice Address - Street 1:12 BANK ST STE 201
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3661
Practice Address - Country:US
Practice Address - Phone:908-376-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA074625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ083830AUKMedicare ID - Type Unspecified
NJI18461Medicare UPIN