Healthcare Provider Details

I. General information

NPI: 1568673028
Provider Name (Legal Business Name): JACK D FAIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 BIENVILLE ST
NATCHITOCHES LA
71457-5730
US

IV. Provider business mailing address

615 BIENVILLE ST
NATCHITOCHES LA
71457-5730
US

V. Phone/Fax

Practice location:
  • Phone: 318-352-6800
  • Fax: 318-352-6803
Mailing address:
  • Phone: 318-352-6800
  • Fax: 318-352-6803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number202650
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: