Provider Demographics
NPI:1134514532
Name:FARIDI, JEESHAN ALI (MD)
Entity Type:Individual
Prefix:
First Name:JEESHAN
Middle Name:ALI
Last Name:FARIDI
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:
Practice Address - Street 1:875 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2529
Practice Address - Country:US
Practice Address - Phone:502-348-5685
Practice Address - Fax:502-348-1771
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02615207X00000X, 207X00000X
KY58849207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100432810Medicaid