Provider Demographics
NPI:1861585432
Name:FAGAN, JUSTIN ROBERT
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ROBERT
Last Name:FAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-4008
Mailing Address - Country:US
Mailing Address - Phone:914-245-4494
Mailing Address - Fax:914-962-2699
Practice Address - Street 1:28 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ARMONK
Practice Address - State:NY
Practice Address - Zip Code:10504-1824
Practice Address - Country:US
Practice Address - Phone:914-273-3485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008283-2111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX94731Medicare ID - Type Unspecified