Provider Demographics
NPI:1023069929
Name:FAIRLEY, JANET (MD)
Entity type:Individual
Prefix:DR
First Name:JANET
Middle Name:
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2856
Mailing Address - Fax:319-356-8317
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2856
Practice Address - Fax:319-356-8317
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30557207N00000X
IA36986207N00000X, 207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA29453OtherWELLMARK BCBS
WI31532900Medicaid
IA0744656Medicaid
IA29453OtherWELLMARK BCBS
IAP00434484Medicare PIN
0080973601Medicare ID - Type Unspecified
IA0744656Medicaid