Individual
JOHNNIE WAYNE FAIRCLOTH JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1400 S COULTER ST, AMARILLO, TX 79106-1786
(806) 414-9800
(806) 354-5689
Mailing address
1400 WALLACE BLVD, AMARILLO, TX 79106-1708
(806) 414-9800
(806) 354-5689
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
N7537
TX
2080S0010X
Pediatric Sports Medicine Physician
N7537
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200340500 A
—
OK
05
—
280457702
—
TX
05
—
280457704
—
TX
05
—
67474560
—
NM
Enumeration date
06/24/2008
Last updated
07/18/2016
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