Provider Demographics
NPI:1194702761
Name:FAGEN, LEONARD (DPM)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:
Last Name:FAGEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1571
Mailing Address - Street 2:8 WOODLAND WAY
Mailing Address - City:QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11959-1571
Mailing Address - Country:US
Mailing Address - Phone:631-653-0077
Mailing Address - Fax:631-653-3388
Practice Address - Street 1:8 WOODLAND WAY
Practice Address - Street 2:
Practice Address - City:QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11959-1571
Practice Address - Country:US
Practice Address - Phone:631-653-0077
Practice Address - Fax:631-653-3388
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2044213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT50640Medicare UPIN