Provider Demographics
NPI:1417053836
Name:FARS, ROBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:FARS
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 1:813 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2729
Mailing Address - Country:US
Mailing Address - Phone:307-673-5501
Mailing Address - Fax:307-673-5434
Practice Address - Street 1:813 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2729
Practice Address - Country:US
Practice Address - Phone:307-673-5501
Practice Address - Fax:307-673-5434
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6773A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY6773AOtherLICENSE
WY6773AOtherLICENSE
WYBF7998923OtherDEA
WY6773AOtherLICENSE