Provider Demographics
NPI:1659428969
Name:FARIES, MARK B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:FARIES
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 1:20 YORK STREET
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510
Mailing Address - Country:US
Mailing Address - Phone:203-785-3577
Mailing Address - Fax:203-737-4067
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:SMILOW CANCER HOSPITAL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-3577
Practice Address - Fax:203-737-4067
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80132208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH71598Medicare UPIN