Provider Demographics
NPI:1801827019
Name:FAGAN, JOHN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:FAGAN
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 1:2080 SOUTH FRONTAGE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180
Mailing Address - Country:US
Mailing Address - Phone:601-262-1000
Mailing Address - Fax:601-262-1006
Practice Address - Street 1:2200 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8246
Practice Address - Country:US
Practice Address - Phone:601-883-5940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12624208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016970Medicaid
MS4547365OtherAETNA
LA1901474Medicaid
MS00016970Medicaid
LA1901474Medicaid
MS00016970Medicaid
LA1901474Medicaid
MS340018678Medicare PIN
MS340000210Medicare PIN