Provider Demographics
NPI:1003888207
Name:FARIS, KEVIN JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAY
Last Name:FARIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2096
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-2096
Mailing Address - Country:US
Mailing Address - Phone:405-872-5403
Mailing Address - Fax:405-872-5407
Practice Address - Street 1:205 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-9623
Practice Address - Country:US
Practice Address - Phone:405-872-5403
Practice Address - Fax:405-872-5407
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3025207R00000X
OK16675207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100130750AMedicaid
OK400522556OtherMEDICARE GRP #
OK110186683OtherRAILROAD MEDICARE
OK244606102Medicare ID - Type Unspecified
OK100130750AMedicaid