Provider Demographics
NPI:1568673028
Name:FAIR, JACK D (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:FAIR
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 1:615 BIENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5730
Mailing Address - Country:US
Mailing Address - Phone:318-352-6800
Mailing Address - Fax:318-352-6803
Practice Address - Street 1:615 BIENVILLE ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5730
Practice Address - Country:US
Practice Address - Phone:318-352-6800
Practice Address - Fax:318-352-6803
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA202650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09966Medicaid