Provider Demographics
NPI:1831179373
Name:FAGAN, MARTHA E (MD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:E
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 1:1050 REID PARKWAY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1156
Mailing Address - Country:US
Mailing Address - Phone:765-962-9541
Mailing Address - Fax:765-966-5952
Practice Address - Street 1:1050 REID PARKWAY
Practice Address - Street 2:SUITE 220
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1156
Practice Address - Country:US
Practice Address - Phone:765-962-9541
Practice Address - Fax:765-966-5952
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066632A207V00000X
VA0101233798207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200946410Medicaid
OH3033461Medicaid
902530HMedicare PIN