Provider Demographics
NPI:1306850797
Name:FAIRCHILD, JEROME PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:PAUL
Last Name:FAIRCHILD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 FONTAINE ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2019
Mailing Address - Country:US
Mailing Address - Phone:850-474-4775
Mailing Address - Fax:850-484-8223
Practice Address - Street 1:530 FONTAINE ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2019
Practice Address - Country:US
Practice Address - Phone:850-474-4775
Practice Address - Fax:850-484-8223
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63676207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
18588Medicare ID - Type Unspecified
F52545Medicare UPIN