1710978655 NPI number — DR. KELLY EDWIN FARRIS M.D.

Table of content: DR. KELLY EDWIN FARRIS M.D. (NPI 1710978655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710978655 NPI number — DR. KELLY EDWIN FARRIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARRIS
Provider First Name:
KELLY
Provider Middle Name:
EDWIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710978655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 W WHEATLAND RD
Provider Second Line Business Mailing Address:
PAV III STE#360
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75237-4408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-884-4700
Provider Business Mailing Address Fax Number:
214-884-4762

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 EAST FM 544
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
MURPHY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75094-4080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-722-6600
Provider Business Practice Location Address Fax Number:
972-722-6601
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  K8143 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 047500601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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