Provider Demographics
NPI:1104261726
Name:FAGAN, MARIE LOUISE (IDC)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:LOUISE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 32ND ST
Mailing Address - Street 2:APT 8
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2080
Mailing Address - Country:US
Mailing Address - Phone:678-764-4067
Mailing Address - Fax:
Practice Address - Street 1:4077 32ND ST
Practice Address - Street 2:APT 8
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2080
Practice Address - Country:US
Practice Address - Phone:678-764-4067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710-1002XOtherIDC