Provider Demographics
NPI:1689849523
Name:FAIRCLOTH, ERICA A (MD, PC)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:A
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3970 SOUTH 700 EAST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-261-3605
Mailing Address - Fax:801-262-9142
Practice Address - Street 1:3970 SOUTH 700 EAST
Practice Address - Street 2:SUITE 14
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-261-3605
Practice Address - Fax:801-262-9142
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ81764207V00000X
UT7256620-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
81764OtherTRAINING PERMIT
UT1689849523Medicaid