Provider Demographics
NPI:1811903677
Name:FAHRNER, LESTER J (MD)
Entity type:Individual
Prefix:DR
First Name:LESTER
Middle Name:J
Last Name:FAHRNER
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 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-8107
Mailing Address - Fax:
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3909
Practice Address - Country:US
Practice Address - Phone:217-366-1248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077871207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070004611OtherRAILROAD MEDICARE
279500OtherMEDICARE GROUP
IL036077871 1Medicaid
279500OtherMEDICARE GROUP
070004611OtherRAILROAD MEDICARE
ILC68803Medicare UPIN