Healthcare Provider Details

I. General information

NPI: 1285694042
Provider Name (Legal Business Name): KEVAGHN P. FAIR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 02/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 BOUSH ST SUITE 200
NORFOLK VA
23510-1501
US

IV. Provider business mailing address

PO BOX 2453
NORFOLK VA
23501-2453
US

V. Phone/Fax

Practice location:
  • Phone: 757-664-7901
  • Fax:
Mailing address:
  • Phone: 757-664-7901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number0102050191
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0102050191
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: