Provider Demographics
NPI:1598751539
Name:FAHY, THERESA (DPM)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:FAHY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:FAHY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:510 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-9990
Mailing Address - Country:US
Mailing Address - Phone:304-263-0811
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9990
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000833213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U02873Medicare UPIN
VA735799Medicare ID - Type Unspecified