Basic Information
| Provider Information | |||||||||
| NPI: | 1518994573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARRAGO | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1149 VISTA PARK DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245514684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346162455 | ||||||||
| FaxNumber: | 4342531806 | ||||||||
| Practice Location | |||||||||
| Address1: | 1149 VISTA PARK DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245514684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346162455 | ||||||||
| FaxNumber: | 4342531806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 014273 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 294100099 | 05 | ME | MEDICAID |