Provider Demographics
NPI:1336396761
Name:BURT FAIBISOFF, MD, PLLC
Entity Type:Organization
Organization Name:BURT FAIBISOFF, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BURT
Authorized Official - Middle Name:I
Authorized Official - Last Name:FAIBISOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-680-7707
Mailing Address - Street 1:2035 MESQUITE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5894
Mailing Address - Country:US
Mailing Address - Phone:928-680-7707
Mailing Address - Fax:928-680-7773
Practice Address - Street 1:2035 MESQUITE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5894
Practice Address - Country:US
Practice Address - Phone:928-680-7707
Practice Address - Fax:928-680-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13213208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C99450Medicare UPIN