Provider Demographics
NPI:1013056357
Name:FAIRBANKS, GRANT ANDREAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:ANDREAS
Last Name:FAIRBANKS
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 1:520 MEDICAL DR 210
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8903
Mailing Address - Country:US
Mailing Address - Phone:801-701-8688
Mailing Address - Fax:801-701-8689
Practice Address - Street 1:1151 EAST 3900 SOUTH
Practice Address - Street 2:SUITE #B110
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-268-8838
Practice Address - Fax:801-268-8264
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2744901205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005817901Medicare ID - Type Unspecified
I50103Medicare UPIN