Provider Demographics
NPI:1568464048
Name:OWIESY, FARO (MD)
Entity Type:Individual
Prefix:DR
First Name:FARO
Middle Name:
Last Name:OWIESY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FARO
Other - Middle Name:T
Other - Last Name:OWIESY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:802 MAGNOLIA AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3125
Mailing Address - Country:US
Mailing Address - Phone:951-371-9500
Mailing Address - Fax:951-278-8182
Practice Address - Street 1:1820 FULLERTON AVE STE 120
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3100
Practice Address - Country:US
Practice Address - Phone:951-371-9500
Practice Address - Fax:951-371-9194
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-13
Last Update Date:2024-01-18
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
CAA87796207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A877961Medicaid
CA00A877960Medicare PIN
CAI12198Medicare UPIN