Provider Demographics
NPI:1104888783
Name:FAY, JOHN MATTHEW (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MATTHEW
Last Name:FAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3917 WEST ROAD
Mailing Address - Street 2:SUITE A MANNM
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-661-8900
Mailing Address - Fax:505-661-8916
Practice Address - Street 1:3917 WEST ROAD
Practice Address - Street 2:SUITE A MANNM
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-661-8900
Practice Address - Fax:505-661-8916
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-01-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CODR44193207Q00000X
NMMD20060672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53123877Medicaid
342701804Medicare PIN
NM53123877Medicaid