Provider Demographics
NPI:1184645814
Name:FAIRBANK, JONATHAN T (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:T
Last Name:FAIRBANK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:283 SPEAR ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:VT
Mailing Address - Zip Code:05445-9132
Mailing Address - Country:US
Mailing Address - Phone:802-847-3592
Mailing Address - Fax:802-847-4822
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:DEPT. OF RADIOLOGY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-3592
Practice Address - Fax:802-847-4822
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT042-00037612085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT4755Medicaid
VT4755Medicaid
VTB85600Medicare UPIN