=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780647933
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN A FABER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2006
-----------------------------------------------------
Last Update Date | 03/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 W JOHN CARPENTER FWY
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75063-3228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-759-4308
-----------------------------------------------------
Fax | 817-335-9100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5621 ROWLETT CREEK WAY
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-7082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-274-8801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 04178
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------