Provider Demographics
NPI:1134143837
Name:KHAIRY, FAROUK
Entity Type:Individual
Prefix:
First Name:FAROUK
Middle Name:
Last Name:KHAIRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6605 MOSSY ROCK LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-2939
Mailing Address - Country:US
Mailing Address - Phone:317-791-9527
Mailing Address - Fax:
Practice Address - Street 1:9015 E 17TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2016
Practice Address - Country:US
Practice Address - Phone:317-355-7700
Practice Address - Fax:317-355-9027
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045094A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00140979OtherRR MEDICARE
IN000000334996OtherANTHEM
IN200034460Medicaid
INF90060Medicare UPIN
IN200034460Medicaid
INM400041127Medicare PIN