Provider Demographics
NPI:1770508905
Name:FARNUM, LAURA MARJORIE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARJORIE
Last Name:FARNUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 REPUBLIC PKWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6917
Mailing Address - Country:US
Mailing Address - Phone:972-279-7575
Mailing Address - Fax:972-270-0197
Practice Address - Street 1:1650 REPUBLIC PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6917
Practice Address - Country:US
Practice Address - Phone:972-279-7575
Practice Address - Fax:972-270-0197
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5309207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB64675Medicare UPIN
TX88T898Medicare ID - Type Unspecified