Provider Demographics
NPI:1629358411
Name:MICHAEL K FAIRBANKS DPM A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL K FAIRBANKS DPM A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:619-465-4972
Mailing Address - Street 1:7750 EASTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7882
Mailing Address - Country:US
Mailing Address - Phone:619-465-4972
Mailing Address - Fax:
Practice Address - Street 1:425 W BONITA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2541
Practice Address - Country:US
Practice Address - Phone:909-599-0981
Practice Address - Fax:909-592-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2726213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFO661AMedicare PIN