Provider Demographics
NPI:1740488543
Name:FAGAN, MATTHEW J (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:FAGAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1187
Mailing Address - Country:US
Mailing Address - Phone:707-638-5232
Mailing Address - Fax:707-638-5255
Practice Address - Street 1:365 TUOLUMNE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5700
Practice Address - Country:US
Practice Address - Phone:707-553-5509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13007207Q00000X
VA0116019758207Q00000X
DCDO034331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine