Provider Demographics
NPI:1730128695
Name:FAIBISOFF, BURT I (MD)
Entity type:Individual
Prefix:
First Name:BURT
Middle Name:I
Last Name:FAIBISOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 AUTUMN WALK
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-2112
Mailing Address - Country:US
Mailing Address - Phone:602-476-4074
Mailing Address - Fax:
Practice Address - Street 1:804 AINSWORTH DR STE 105
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1624
Practice Address - Country:US
Practice Address - Phone:928-515-1155
Practice Address - Fax:928-460-5158
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ132132082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ226672Medicaid
AZ226672Medicaid
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