Provider Demographics
NPI:1538184791
Name:FAGAN, MATTHEW J (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
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 1:200 HYGEIA DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4375 OGLETOWN STANTON ROAD
Practice Address - Street 2:SUITE 1208
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2089
Practice Address - Country:US
Practice Address - Phone:302-623-4055
Practice Address - Fax:302-623-4056
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429235207VF0040X, 207VG0400X, 2088F0040X
DEC10011078207VG0400X, 207VF0040X
DEC1-00110782088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No2088F0040XAllopathic & Osteopathic PhysiciansUrologyUrogynecology and Reconstructive Pelvic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016687780001Medicaid
H94982Medicare UPIN
PA1016687780001Medicaid