Provider Demographics
NPI:1669491288
Name:FAIRBANKS, JOHN H (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 FRONT ST
Mailing Address - Street 2:SUITE 2134
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-2836
Mailing Address - Country:US
Mailing Address - Phone:318-336-2212
Mailing Address - Fax:318-336-6067
Practice Address - Street 1:107 FRONT ST
Practice Address - Street 2:SUITE 2134
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2836
Practice Address - Country:US
Practice Address - Phone:318-336-2212
Practice Address - Fax:318-336-6067
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15703207X00000X
LAMD.017268207XX0005X
LAMD017268207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119142Medicaid
LA1384101Medicaid
LA1384101Medicaid
D87020Medicare UPIN
MS00119142Medicaid