Healthcare Provider Details

I. General information

NPI: 1790790251
Provider Name (Legal Business Name): JEFFREY COX FAHL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 NEW SCOTLAND AVE MAIL CODE 88
ALBANY NY
12208-3478
US

IV. Provider business mailing address

PO BOX 5371 4800 SAND POINT WAY NE
SEATTLE WA
98145-5005
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-8831
  • Fax: 518-262-6453
Mailing address:
  • Phone: 206-987-1036
  • Fax: 206-987-2721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number300829
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: