Provider Demographics
NPI:1295838365
Name:FAIR, BENNY JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:BENNY
Middle Name:
Last Name:FAIR
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:BENNY
Other - Middle Name:
Other - Last Name:FAIR
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:2700 LAFAYETTE ST
Mailing Address - Street 2:STE 100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-1100
Mailing Address - Country:US
Mailing Address - Phone:260-458-9953
Mailing Address - Fax:260-458-9238
Practice Address - Street 1:2700 LAFAYETTE ST
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1100
Practice Address - Country:US
Practice Address - Phone:260-458-9953
Practice Address - Fax:260-458-9238
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000728213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00128864OtherRR MEDICARE
IN100082090AMedicaid
000000331259OtherBLUE CROSS
IN100082090AMedicaid
000000331259OtherBLUE CROSS
U27211Medicare UPIN