Provider Demographics
NPI:1700989969
Name:FAIRBANKS, DAVID W (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
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 1:203 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-2012
Mailing Address - Country:US
Mailing Address - Phone:575-445-7720
Mailing Address - Fax:575-383-3332
Practice Address - Street 1:203 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2012
Practice Address - Country:US
Practice Address - Phone:575-445-7720
Practice Address - Fax:575-445-7737
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16369207P00000X
UT6372524-1205207P00000X, 207Q00000X
NMMD2022-0625207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87155028Medicaid
WV3810005265Medicaid