Provider Demographics
NPI:1285694042
Name:FAIR, KEVAGHN P (DO)
Entity type:Individual
Prefix:DR
First Name:KEVAGHN
Middle Name:P
Last Name:FAIR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2453
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-2453
Mailing Address - Country:US
Mailing Address - Phone:757-664-7901
Mailing Address - Fax:
Practice Address - Street 1:733 BOUSH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1501
Practice Address - Country:US
Practice Address - Phone:757-664-7901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102050191207ZD0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4991427Medicaid
VAH35179Medicare UPIN
VA4991427Medicaid