Healthcare Provider Details

I. General information

NPI: 1376645283
Provider Name (Legal Business Name): JOHN LAWRENCE FAIRBANKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 MEDICAL ARTS DR SUITE 105
FLOWER MOUND TX
75028-1712
US

IV. Provider business mailing address

3600 GASTON AVE SUITE 1205
DALLAS TX
75246-1800
US

V. Phone/Fax

Practice location:
  • Phone: 214-394-4500
  • Fax: 214-513-2059
Mailing address:
  • Phone: 214-692-8262
  • Fax: 214-696-4190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberJ9018
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: