Provider Demographics
NPI:1811095045
Name:FAGERLAND, JEFFREY JAY (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAY
Last Name:FAGERLAND
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 1:330 LAUREL ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-3044
Mailing Address - Country:US
Mailing Address - Phone:515-288-3287
Mailing Address - Fax:
Practice Address - Street 1:330 LAUREL ST STE 1100
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3044
Practice Address - Country:US
Practice Address - Phone:515-288-3287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02469207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2102251Medicaid
IA58954Medicare ID - Type Unspecified
IA2102251Medicaid