Provider Demographics
NPI:1114972429
Name:FAIRBANKS, MARY LINDA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LINDA
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY LINDA
Other - Middle Name:KRECK
Other - Last Name:FAIRBANKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1400 FOREST GLEN RD
Mailing Address - Street 2:SUITE 525
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1459
Mailing Address - Country:US
Mailing Address - Phone:301-593-8101
Mailing Address - Fax:301-593-1537
Practice Address - Street 1:1400 FOREST GLEN RD
Practice Address - Street 2:SUITE 525
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1459
Practice Address - Country:US
Practice Address - Phone:301-593-8101
Practice Address - Fax:301-593-1537
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0071536207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7378633OtherAETNA
P020233010OtherBLUE SHIELD