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General NPI Number Information
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NPI Number | 1336396761
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Entity Type | Organization
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Legal Business Name | BURT FAIBISOFF, MD, PLLC
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Dates
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Enumeration Date | 08/27/2008
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Last Update Date | 08/27/2008
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Provider Practice Location Address
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Address Line | 2035 MESQUITE AVE SUITE A
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5894
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Country | US
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Telephone | 928-680-7707
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Fax | 928-680-7773
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Provider Business Mailing Address
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Address Line | 2035 MESQUITE AVE SUITE A
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5894
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Country | US
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Telephone | 928-680-7707
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Fax | 928-680-7773
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Authorized Official
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Title or Position | MEMBER
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Name | DR. BURT I. FAIBISOFF
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Credential | MD
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Telephone | 928-680-7707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 13213
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License Number State | AZ
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