Individual
IAN LESTER FAWKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
3801 S NATIONAL AVE, SPRINGFIELD, MO 65807-5210
(417) 269-7728
(417) 269-7729
Mailing address
PO BOX 505673, SAINT LOUIS, MO 63150-5673
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
115964
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
129355
BLUE CROSS
—
05
—
244976403
—
MO
Enumeration date
06/28/2005
Last updated
02/26/2025
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