Basic Information
| Provider Information | |||||||||
| NPI: | 1447344577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAGIN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 MARCUS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166226000 | ||||||||
| FaxNumber: | 5166082897 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 DAKOTA DRIVE | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | LAKE SUCCESS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166082898 | ||||||||
| FaxNumber: | 5166082897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0201X | 136140 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
ID Information
| ID | Type | State | Issuer | Description | 01120598 | 05 | NY | MEDICAID |