Provider Demographics
NPI:1982635504
Name:FABIAN, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:FABIAN
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 1:80 MEAD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-4435
Mailing Address - Country:US
Mailing Address - Phone:716-693-1596
Mailing Address - Fax:716-743-0812
Practice Address - Street 1:80 MEAD ST
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-4435
Practice Address - Country:US
Practice Address - Phone:716-693-1596
Practice Address - Fax:716-743-0812
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186089207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000511201003OtherBC/BS OF WESTERN NEW YORK
NY00010052501OtherEXCELLUS/ UNIVERA INS. CO
NY01280359Medicaid
NY0403772OtherINDEPENDENT HEALTH INS.
NY01280359Medicaid
NY283381Medicare ID - Type Unspecified