Provider Demographics
NPI:1457351223
Name:FAIR, SUSAN CAROLE (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROLE
Last Name:FAIR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 N COURTENAY PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4851
Mailing Address - Country:US
Mailing Address - Phone:321-455-1226
Mailing Address - Fax:321-456-5531
Practice Address - Street 1:595 N COURTENAY PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4851
Practice Address - Country:US
Practice Address - Phone:321-455-1226
Practice Address - Fax:321-456-5531
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46520YMedicare ID - Type Unspecified
G94127Medicare UPIN