Provider Demographics
NPI:1104094887
Name:DR. MICHAEL FAGIN , P.C.
Entity type:Organization
Organization Name:DR. MICHAEL FAGIN , P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAGIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-815-8302
Mailing Address - Street 1:2007 E GREYHOUND PASS
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-7808
Mailing Address - Country:US
Mailing Address - Phone:317-815-8302
Mailing Address - Fax:
Practice Address - Street 1:2007 E GREYHOUND PASS
Practice Address - Street 2:SUITE 4
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-7808
Practice Address - Country:US
Practice Address - Phone:317-815-8302
Practice Address - Fax:317-815-8305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002571B152WC0802X
IN18002571152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U35438Medicare UPIN