Provider Demographics
NPI: | 1164597498 |
---|---|
Name: | FAIRBANKS DOANE, LAURI ANN (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | LAURI |
Middle Name: | ANN |
Last Name: | FAIRBANKS DOANE |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | LAURI |
Other - Middle Name: | ANN |
Other - Last Name: | FAIRBANKS |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | DO |
Mailing Address - Street 1: | 8100 OSWEGO ROAD |
Mailing Address - Street 2: | SUITE 220 |
Mailing Address - City: | LIVERPOOL |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 13090 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 315-652-6551 |
Mailing Address - Fax: | 315-652-9698 |
Practice Address - Street 1: | 8100 OSWEGO ROAD |
Practice Address - Street 2: | SUITE 220 |
Practice Address - City: | LIVERPOOL |
Practice Address - State: | NY |
Practice Address - Zip Code: | 13090 |
Practice Address - Country: | US |
Practice Address - Phone: | 315-652-6551 |
Practice Address - Fax: | 315-652-9698 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-11-21 |
Last Update Date: | 2008-05-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 197300 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
080178302 | Other | RAILROAD MEDICARE | |
NY | 01918827 | Medicaid | |
960897 | Other | MVP HEALTHCARE INSURER | |
G25714 | Medicare UPIN | ||
NY | 01918827 | Medicaid |