Provider Demographics
NPI:1972524486
Name:FAGAN, RONALD C (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:C
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 1:4900 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2028
Mailing Address - Country:US
Mailing Address - Phone:516-752-7000
Mailing Address - Fax:516-586-8644
Practice Address - Street 1:4900 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2028
Practice Address - Country:US
Practice Address - Phone:516-752-7000
Practice Address - Fax:516-586-8644
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178331207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01291969Medicaid
NY03367237Medicaid
NYF18841Medicare UPIN
NY29K941Medicare ID - Type Unspecified