Provider Demographics
NPI:1053480152
Name:FAIRFAX, JON (MD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:
Last Name:FAIRFAX
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 1:1350 S KING ST
Mailing Address - Street 2:SUITE 325
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2008
Mailing Address - Country:US
Mailing Address - Phone:808-591-9116
Mailing Address - Fax:808-591-9655
Practice Address - Street 1:1350 S KING ST
Practice Address - Street 2:SUITE 325
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2008
Practice Address - Country:US
Practice Address - Phone:808-591-9116
Practice Address - Fax:808-591-9655
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD77392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01976602Medicaid
HI01976602Medicaid