Provider Demographics
NPI:1689230138
Name:FAUBION, MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FAUBION
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 1:2816 VINE ST APT 262
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-4088
Mailing Address - Country:US
Mailing Address - Phone:501-837-6692
Mailing Address - Fax:
Practice Address - Street 1:2816 VINE ST APT 262
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-4088
Practice Address - Country:US
Practice Address - Phone:501-837-6692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100668902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX693531OtherTEXAS MEDICAL BOARD PHYSICIAN IN TRAINING ID NUMBER
TXBP10066890OtherTEXAS MEDICAL BOARD PHYSICIAN IN TRAINING PERMIT