Basic Information
| Provider Information | |||||||||
| NPI: | 1740488543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAGAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 CLUB DR | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945921187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076385232 | ||||||||
| FaxNumber: | 7076385255 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 TUOLUMNE ST | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945905700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075535509 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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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 | 207Q00000X | 13007 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0116019758 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO034331 | DC | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.