Provider Demographics
NPI:1417906330
Name:FAIRFAX, CYNTHIA (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:
Last Name:FAIRFAX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 E MAGIC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6245
Mailing Address - Country:US
Mailing Address - Phone:208-639-4900
Mailing Address - Fax:208-639-4901
Practice Address - Street 1:2855 E MAGIC VIEW DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6245
Practice Address - Country:US
Practice Address - Phone:208-639-4900
Practice Address - Fax:208-639-4901
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6803208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010157304OtherBLUE SHIELD MERIDIAN
IDB5600OtherBLUE CROSS MERIDIAN
ID000010000852OtherBLUE SHIELD BOISE
ID2571800Medicaid
ID75663OtherBLUE CROSS BOISE
DEG04620Medicare UPIN
ID2571800Medicaid