Provider Demographics
NPI:1184693913
Name:FAIRCLOTH, SONYA C (DPM)
Entity type:Individual
Prefix:DR
First Name:SONYA
Middle Name:C
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9766 MIDLOTHIAN TPKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4973
Mailing Address - Country:US
Mailing Address - Phone:804-330-2467
Mailing Address - Fax:804-330-3366
Practice Address - Street 1:9766 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-4973
Practice Address - Country:US
Practice Address - Phone:804-330-2467
Practice Address - Fax:804-330-3366
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000905213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9300473Medicaid
U44326Medicare UPIN