Basic Information
| Provider Information | |||||||||
| NPI: | 1033227806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAGUNDES | ||||||||
| FirstName: | HUMBERTO | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 W PORT PLZ | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145484772 | ||||||||
| FaxNumber: | 3145484748 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 N NEW BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149965180 | ||||||||
| FaxNumber: | 3148212180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 09/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 100121 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0202X | 100121 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 32286 | 01 | BNDD | OTHER | 100121 | 01 | MO LICENSE | OTHER | 33012444 | 01 | CPIN | OTHER | 920004686 | 01 | RRMEDICARE | OTHER | BF3076127 | 01 | DEA | OTHER | 207947516 | 01 | MCAID | OTHER |