Provider Demographics
NPI:1578678926
Name:FAIRBANKS, MICHAEL K (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W BONITA AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2543
Mailing Address - Country:US
Mailing Address - Phone:909-599-0981
Mailing Address - Fax:
Practice Address - Street 1:425 W BONITA AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2543
Practice Address - Country:US
Practice Address - Phone:909-599-0981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2726213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E27260Medicaid
CAE2726Medicare ID - Type Unspecified
CAT19228Medicare UPIN
CA480029085Medicare ID - Type UnspecifiedRAILROAD