Basic Information
Provider Information | |||||||||
NPI: | 1700976974 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FARR | ||||||||
FirstName: | MARYJANE | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 845347 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752847208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: | 2123057439 | ||||||||
Practice Location | |||||||||
Address1: | 5939 HARRY HINES BLVD | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753903720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146455505 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2006 | ||||||||
LastUpdateDate: | 09/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 217712 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 61844 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RA0001X | 217712 | NY | N |   |   |   |   | 207RC0000X | 217712 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | T2599 | TX | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 02591413 | 05 | NY |   | MEDICAID | 61844 | 01 | CT | CT STATE LICENSE | OTHER |