Basic Information
| Provider Information | |||||||||
| NPI: | 1780606004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIR | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | HASKELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 918025 | ||||||||
| Address2: | SUITE 590 W | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328918025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650604 | ||||||||
| FaxNumber: | 3522650190 | ||||||||
| Practice Location | |||||||||
| Address1: | 6411 FANNIN ST # J1.400 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137044071 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME111974 | FL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 29106 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | R4219 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 004578500 | 05 | FL | MEDICAID | 8931062 | 05 | NC | MEDICAID |