Provider Demographics
NPI:1760406862
Name:FARY, DANIEL RB (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RB
Last Name:FARY
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 1:512 WILCOX ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1254
Mailing Address - Country:US
Mailing Address - Phone:920-563-7366
Mailing Address - Fax:920-563-9061
Practice Address - Street 1:512 WILCOX ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1254
Practice Address - Country:US
Practice Address - Phone:920-563-7366
Practice Address - Fax:920-563-9061
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22350-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30293500Medicaid
WI30293500Medicaid