Provider Demographics
NPI:1427192863
Name:FARK, ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:FARK
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 1:3802 PAXTON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-2399
Mailing Address - Country:US
Mailing Address - Phone:513-559-9700
Mailing Address - Fax:513-559-0900
Practice Address - Street 1:1061 DECKER DR
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-6415
Practice Address - Country:US
Practice Address - Phone:231-492-4587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.093391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3110869Medicaid
MIMI430448957OtherBLUE CROSS PIN
IN200997410Medicaid
MIAF048957OtherBLUE SHIELD PIN
MI104462999Medicaid
MI104462999Medicaid
OHH026420Medicare PIN
OH3110869Medicaid