Provider Demographics
NPI:1104812171
Name:FAGAN, LEONARD SIMON (MD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:SIMON
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-389-2233
Mailing Address - Fax:
Practice Address - Street 1:10222 74TH STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-6800
Practice Address - Country:US
Practice Address - Phone:262-697-9200
Practice Address - Fax:262-697-9206
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46372-020174400000X
WI46372207V00000X
FLME157114207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34485700Medicaid
D16680Medicare UPIN
WI000132399Medicare ID - Type Unspecified