Individual
JOHN DAVID FAGAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2200 HIGHWAY 61 N, VICKSBURG, MS 39183-8246
(601) 883-5940
Mailing address
2080 SOUTH FRONTAGE RD, SUITE 100, VICKSBURG, MS 39180
(601) 262-1000
(601) 262-1006
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
12624
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00016970
—
MS
05
—
1901474
—
LA
01
—
4547365
AETNA
MS
Enumeration date
07/05/2006
Last updated
09/10/2020
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