Provider Demographics
NPI:1447495585
Name:FAGAN, SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
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 1:7460 WARREN PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-4170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:800-514-1722
Practice Address - Street 1:7460 WARREN PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4170
Practice Address - Country:US
Practice Address - Phone:496-287-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21413208D00000X
LAMD. 202440208D00000X
TXR5388208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1358347Medicaid
LA1358347Medicaid
MS1358347Medicaid
LA4N508Medicare PIN