Provider Demographics
NPI:1164597498
Name:FAIRBANKS DOANE, LAURI ANN (DO)
Entity type:Individual
Prefix:
First Name:LAURI
Middle Name:ANN
Last Name:FAIRBANKS DOANE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAURI
Other - Middle Name:ANN
Other - Last Name:FAIRBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:8100 OSWEGO ROAD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-652-6551
Mailing Address - Fax:315-652-9698
Practice Address - Street 1:8100 OSWEGO ROAD
Practice Address - Street 2:SUITE 220
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-652-6551
Practice Address - Fax:315-652-9698
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080178302OtherRAILROAD MEDICARE
NY01918827Medicaid
960897OtherMVP HEALTHCARE INSURER
G25714Medicare UPIN
NY01918827Medicaid