Provider Demographics
NPI:1427147669
Name:FAGIN, MICHAEL L (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:FAGIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13753 STONE DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-9412
Mailing Address - Country:US
Mailing Address - Phone:317-574-9276
Mailing Address - Fax:
Practice Address - Street 1:2007 E GREYHOUND PASS STE 4
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-7753
Practice Address - Country:US
Practice Address - Phone:317-815-8302
Practice Address - Fax:317-815-8305
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002571A152W00000X
IN18002571B152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18002571OtherSTATE LICENSE
138650FMedicare ID - Type Unspecified
U35438Medicare UPIN