Provider Demographics
NPI:1770016453
Name:FAIRBANKS, JEREMIAH DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:DOUGLAS
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-2687
Mailing Address - Country:US
Mailing Address - Phone:651-438-1800
Mailing Address - Fax:
Practice Address - Street 1:1880 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2687
Practice Address - Country:US
Practice Address - Phone:651-438-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-09
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN64281207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty