Provider Demographics
NPI:1376645283
Name:FAIRBANKS, JOHN LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LAWRENCE
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 1205
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:4370 MEDICAL ARTS DR
Practice Address - Street 2:SUITE 105
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1712
Practice Address - Country:US
Practice Address - Phone:214-394-4500
Practice Address - Fax:214-513-2059
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ9018208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117289212Medicaid
TX117289211Medicaid
TXP01601410OtherRRMCR
TX117289211Medicaid
TX274158YX28Medicare PIN
TXP01601410OtherRRMCR
TX274158YX28Medicare PIN
G14442Medicare UPIN
TX274158YX28Medicare PIN