=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295838365
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENNY FAIR JR. D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 LAFAYETTE ST SUITE 120
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46806-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-458-9953
-----------------------------------------------------
Fax | 260-458-9238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 LAFAYETTE ST STE 100
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46806-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-458-9953
-----------------------------------------------------
Fax | 260-458-9238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 07000728
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------