Provider Demographics
NPI:1588711717
Name:FAIRCLOTH, RON CHRISTOPHER (OD)
Entity type:Individual
Prefix:
First Name:RON
Middle Name:CHRISTOPHER
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:RON
Other - Middle Name:C
Other - Last Name:FAIRCLOTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:2170 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-2927
Mailing Address - Country:US
Mailing Address - Phone:910-295-2100
Mailing Address - Fax:
Practice Address - Street 1:404 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3223
Practice Address - Country:US
Practice Address - Phone:910-875-5114
Practice Address - Fax:910-875-8503
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908094Medicaid
NC5908094Medicaid
NC2471251AMedicare PIN