Provider Demographics
NPI:1427009521
Name:FAIRCLOTH, VIVIAN C (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:C
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:JOSEPHINE
Other - Last Name:CLOUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-5503
Mailing Address - Fax:717-851-5507
Practice Address - Street 1:1695 ROOSEVELT AVE STE B
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-8521
Practice Address - Country:US
Practice Address - Phone:717-851-5503
Practice Address - Fax:717-798-3510
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABF75102122084N0400X
FLME1287512084N0400X
PAMD073033L2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA959225OtherHIGHMARK BLUE SHIELD
PA30151150OtherAMERIHEALTH CARITAS PA - WMG
PA1517367OtherGATEWAY
PAP01331224Medicare PIN
PA1517367OtherGATEWAY
PA228512FLTMedicare PIN