Provider Demographics
NPI:1376657668
Name:FAIR, GREGORY A (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:FAIR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N LISBON ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615-1327
Mailing Address - Country:US
Mailing Address - Phone:330-627-2430
Mailing Address - Fax:
Practice Address - Street 1:113 N LISBON ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-1327
Practice Address - Country:US
Practice Address - Phone:330-627-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0464810001OtherRAILROAD MEDICARE
OH0561299Medicaid
T48240Medicare UPIN
FA0571732Medicare PIN