Healthcare Provider Details

I. General information

NPI: 1184645814
Provider Name (Legal Business Name): JONATHAN T FAIRBANK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE DEPT. OF RADIOLOGY
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

283 SPEAR ST
CHARLOTTE VT
05445-9132
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3592
  • Fax: 802-847-4822
Mailing address:
  • Phone: 802-847-3592
  • Fax: 802-847-4822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number042-0003761
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: