1376645283 NPI number — JOHN LAWRENCE FAIRBANKS MD

Table of content: JOHN LAWRENCE FAIRBANKS MD (NPI 1376645283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376645283 NPI number — JOHN LAWRENCE FAIRBANKS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRBANKS
Provider First Name:
JOHN
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376645283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 GASTON AVE
Provider Second Line Business Mailing Address:
SUITE 1205
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75246-1800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-692-8262
Provider Business Mailing Address Fax Number:
214-696-4190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4370 MEDICAL ARTS DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FLOWER MOUND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75028-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-394-4500
Provider Business Practice Location Address Fax Number:
214-513-2059
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  J9018 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 117289212 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 117289211 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01601410 . This is a "RRMCR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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