Provider Demographics
NPI:1538113592
Name:FEARON, JEFFREY A (MD,FACS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:FEARON
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN STE C700
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2518
Mailing Address - Country:US
Mailing Address - Phone:972-566-6464
Mailing Address - Fax:972-566-6279
Practice Address - Street 1:7777 FOREST LN STE C700
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2518
Practice Address - Country:US
Practice Address - Phone:972-566-6464
Practice Address - Fax:972-566-6279
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH86382086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN000E1668Medicaid
TX10010045Medicaid
TX00X682OtherMEDICARE GROUP PTAN
TX118956501Medicaid
LA1921297Medicaid
MO208847509Medicaid
CO91863803Medicaid
IA0722264OtherIOWA MEDICAID
TX8F5212OtherMEDICARE INDIVIDUAL PTAN
TX118956502Medicaid
TX3858Medicaid
TX5542707OtherAETNA
TX093725201Medicaid
TX86J892OtherBC/BS PROVIDER ID NUMBER
OK100753300AMedicare ID - Type UnspecifiedOKLAHOMA MEDICAID
TX10010045Medicaid