Provider Demographics
NPI:1568990083
Name:FARRIS, KAREN DIANE (DO)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:DIANE
Last Name:FARRIS
Suffix:
Gender:F
Credentials:DO
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 270
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-0270
Mailing Address - Country:US
Mailing Address - Phone:812-723-3944
Mailing Address - Fax:812-723-7989
Practice Address - Street 1:420 W LONGEST ST
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:IN
Practice Address - Zip Code:47454-8821
Practice Address - Country:US
Practice Address - Phone:812-723-3944
Practice Address - Fax:812-723-7989
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02006114A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300043033Medicaid