Healthcare Provider Details

I. General information

NPI: 1295707537
Provider Name (Legal Business Name): DAVID LYNN FAIRBROOK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 NORTHWEST LN SE
LACEY WA
98503-6908
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-491-4460
  • Fax:
Mailing address:
  • Phone: 360-486-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD00013192
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: