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General NPI Number Information
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NPI Number | 1457351223
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Entity Type | Individual
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Provider Name | SUSAN CAROLE FAIR DO
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Gender | Female
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Dates
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Enumeration Date | 07/22/2005
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Last Update Date | 08/01/2007
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Provider Practice Location Address
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Address Line | 595 N COURTENAY PKWY SUITE 102
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-4851
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Country | US
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Telephone | 321-455-1226
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Fax | 321-456-5531
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Provider Business Mailing Address
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Address Line | 595 N COURTENAY PKWY SUITE 102
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-4851
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Country | US
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Telephone | 321-455-1226
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Fax | 321-456-5531
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS7489
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License Number State | FL
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