MEDICARE: DR. BENNY FAIR JR. D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	07000728	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00128864	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000331259	OTHER		BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295838365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENNY FAIR JR. D.P.M.

Provider Business Mailing Address
First Line	:	2700 LAFAYETTE ST
Second Line	:	STE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1100
Country	:	US
Telephone Number	:	260-458-9953
Fax Number	:	260-458-9238

Provider Business Practice Location Address
First Line	:	2700 LAFAYETTE ST
Second Line	:	SUITE 120
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1100
Country	:	US
Telephone Number	:	260-458-9953
Fax Number	:	260-458-9238

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	01/02/2025

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Directions to “ DR. BENNY FAIR JR. D.P.M.” Practice Location

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