Healthcare Provider Details

I. General information

NPI: 1932200144
Provider Name (Legal Business Name): LAURA CRUMP FAIRBANKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 WEBB SMITH DR
COLFAX LA
71417-1910
US

IV. Provider business mailing address

PO BOX 1288
WINNFIELD LA
71483-1288
US

V. Phone/Fax

Practice location:
  • Phone: 318-627-5021
  • Fax: 318-627-5999
Mailing address:
  • Phone: 318-648-0375
  • Fax: 318-648-0378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number304116
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: