Provider Demographics
NPI:1013087055
Name:DOUGLAS A FAIRBAIRN MDLLC
Entity Type:Organization
Organization Name:DOUGLAS A FAIRBAIRN MDLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:AUMILLER
Authorized Official - Last Name:FAIRBAIRN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-559-1111
Mailing Address - Street 1:1978 S GARRISON ST
Mailing Address - Street 2:101
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-2282
Mailing Address - Country:US
Mailing Address - Phone:303-988-1559
Mailing Address - Fax:303-988-1603
Practice Address - Street 1:6816 OTIS ST
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80003-4067
Practice Address - Country:US
Practice Address - Phone:303-559-1111
Practice Address - Fax:303-420-9349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91232830Medicaid
CO91232830Medicaid
COB67910Medicare UPIN