Provider Demographics
NPI:1306863998
Name:FAIRES, RAYMOND A (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
Last Name:FAIRES
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:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-332-2372
Practice Address - Street 1:1325 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 325
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2175
Practice Address - Country:US
Practice Address - Phone:817-878-5325
Practice Address - Fax:817-332-2372
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE63422086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
240008035OtherRAILROAD MEDICARE
TX130279607Medicaid