Provider Demographics
NPI:1821084781
Name:FAIRBANKS, ROBERT KENNETH (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:KENNETH
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 239
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-0239
Mailing Address - Country:US
Mailing Address - Phone:208-799-5600
Mailing Address - Fax:208-799-5755
Practice Address - Street 1:504 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2439
Practice Address - Country:US
Practice Address - Phone:208-799-5600
Practice Address - Fax:208-799-5755
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000376552085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8243958Medicaid
000010032648OtherBLUE SHIELD OF IDAHO
WA0144615OtherLABOR & INDUSTRIES
ID805949200Medicaid
WA3070FAOtherASURIS NW HEALTH
920006292OtherRAILROAD MEDICARE
5034131OtherAETNA
K0716OtherBLUE CROSS OF IDAHO
920006292OtherRAILROAD MEDICARE
WAGAB20699Medicare PIN
WA0144615OtherLABOR & INDUSTRIES