Provider Demographics
NPI:1912168600
Name:FAIRCLOTH, JOHNNIE WAYNE JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:WAYNE
Last Name:FAIRCLOTH
Suffix:JR
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 1:1400 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-414-9800
Mailing Address - Fax:806-354-5689
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-414-9800
Practice Address - Fax:806-354-5689
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7537208000000X, 2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280457704Medicaid
TX280457702Medicaid
OK200340500 AMedicaid
NM67474560Medicaid
OK200340500 AMedicaid