Provider Demographics
NPI:1598876195
Name:FARELLA, JOHN FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FREDERICK
Last Name:FARELLA
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 1:666 LEXINGTON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3638
Mailing Address - Country:US
Mailing Address - Phone:914-241-7111
Mailing Address - Fax:914-241-7445
Practice Address - Street 1:666 LEXINGTON AVE STE 104
Practice Address - Street 2:
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3638
Practice Address - Country:US
Practice Address - Phone:914-241-7111
Practice Address - Fax:914-241-7445
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163861-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01280437Medicaid
NYE98544Medicare UPIN
NY96F302Medicare PIN