Provider Demographics
NPI:1316167877
Name:FAGERSON, DANIEL H (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:H
Last Name:FAGERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1111 OPAL ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1831
Mailing Address - Country:US
Mailing Address - Phone:858-273-0911
Mailing Address - Fax:858-273-0911
Practice Address - Street 1:12264 EL CAMINO REAL
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3058
Practice Address - Country:US
Practice Address - Phone:858-523-9700
Practice Address - Fax:858-523-9711
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG866282085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG53847Medicare UPIN