Provider Demographics
NPI:1073789277
Name:DAVIS G. FARVOLDEN, M.D., LLC
Entity Type:Organization
Organization Name:DAVIS G. FARVOLDEN, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVIS
Authorized Official - Middle Name:GRAHAM
Authorized Official - Last Name:FARVOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-321-5900
Mailing Address - Street 1:7401 OSLER DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7673
Mailing Address - Country:US
Mailing Address - Phone:410-321-5900
Mailing Address - Fax:410-821-6052
Practice Address - Street 1:7401 OSLER DR
Practice Address - Street 2:SUITE 107
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7673
Practice Address - Country:US
Practice Address - Phone:410-321-5900
Practice Address - Fax:410-821-6052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0067218207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I68870Medicare UPIN