Basic Information
| Provider Information | |||||||||
| NPI: | 1841443264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAGLIE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | DARRELL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W EAGLE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406277443 | ||||||||
| FaxNumber: | 9406277464 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 W EAGLE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406277443 | ||||||||
| FaxNumber: | 9406277597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2008 | ||||||||
| LastUpdateDate: | 09/22/2016 | ||||||||
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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 | N5045 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | N5045 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | P00964976 | 01 | TX | RAILROAD MEDICARE | OTHER | 220200401 | 05 | TX | MEDICAID |