Basic Information
| Provider Information | |||||||||
| NPI: | 1851404859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANGMAN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | LEO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1072 X RAY DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046911074 | ||||||||
| FaxNumber: | 7046711095 | ||||||||
| Practice Location | |||||||||
| Address1: | 959 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048667576 | ||||||||
| FaxNumber: | 7048660106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 200201075 | NC | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | ME100630 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | 2019-00293 | NC | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | BF9759955 | 01 | DEA | OTHER | 5904546 | 05 | NC | MEDICAID | 280314300 | 05 | FL | MEDICAID |