Provider Demographics
NPI:1912929068
Name:FAGAN, DAVID G (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
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 1:510 AZALEA DRIVE
Mailing Address - Street 2:
Mailing Address - City:LANETT
Mailing Address - State:AL
Mailing Address - Zip Code:36863
Mailing Address - Country:US
Mailing Address - Phone:334-644-3492
Mailing Address - Fax:
Practice Address - Street 1:11 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3665
Practice Address - Country:US
Practice Address - Phone:334-756-4860
Practice Address - Fax:334-756-4866
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00017725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF79815Medicare UPIN