Healthcare Provider Details

I. General information

NPI: 1336209550
Provider Name (Legal Business Name): J H FAIRBANKS MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FRONT ST SUITE 230
VIDALIA LA
39120
US

IV. Provider business mailing address

107 FRONT ST SUITE 230
VIDALIA LA
39120
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-2212
  • Fax: 318-336-6067
Mailing address:
  • Phone: 318-336-2212
  • Fax: 318-336-6067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number15703
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD017268
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD017268
License Number StateLA

VIII. Authorized Official

Name: ANGEL NICOLE NUGENT
Title or Position: MANAGER
Credential:
Phone: 318-336-2212