Provider Demographics
NPI:1316905508
Name:FAGG, JOHN ANDERSON (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDERSON
Last Name:FAGG
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 1:2901 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-765-8620
Mailing Address - Fax:336-768-6236
Practice Address - Street 1:2901 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-765-8620
Practice Address - Fax:336-768-6236
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001199779208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC240001710OtherRAILROAD MEDICARE
NC8931036Medicaid
NC60623OtherMEDCOST
NC31036OtherBCBS
NC912OtherPARTNERS
NC8931036Medicaid
NC31036OtherBCBS