Provider Demographics
NPI:1912407511
Name:FAIRBANKS, SAMUEL (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:762-408-2001
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:762-408-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022057692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology