Provider Demographics
NPI:1043279235
Name:FARJO, LAITH ANASTAS (MD)
Entity Type:Individual
Prefix:DR
First Name:LAITH
Middle Name:ANASTAS
Last Name:FARJO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 GENOA BUSINESS PARK DR.
Mailing Address - Street 2:SUITE 170
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7367
Mailing Address - Country:US
Mailing Address - Phone:810-299-8550
Mailing Address - Fax:810-844-0837
Practice Address - Street 1:2305 GENOA BUSINESS PARK DR
Practice Address - Street 2:SUITE 170
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7367
Practice Address - Country:US
Practice Address - Phone:810-299-8550
Practice Address - Fax:810-844-0837
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILF073669207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4379981Medicaid
0N41740001Medicare ID - Type Unspecified
MIG07694Medicare UPIN