Provider Demographics
NPI:1417148891
Name:ALFARIS, MOHAMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:ALFARIS
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 1:4030 TATES CREEK RD
Mailing Address - Street 2:APT 2949
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3073
Mailing Address - Country:US
Mailing Address - Phone:859-693-9025
Mailing Address - Fax:
Practice Address - Street 1:4030 TATES CREEK RD
Practice Address - Street 2:APT 2949
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-3073
Practice Address - Country:US
Practice Address - Phone:859-693-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126164207QA0505X
KY44451207P00000X
VA0101259467207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100051520Medicaid
VA1417148891Medicaid
KY7100051520Medicaid
VAVVJ959AMedicare PIN
VA1417148891Medicaid
KY0601455Medicare PIN
KY00280085Medicare PIN