Provider Demographics
NPI:1821093923
Name:FARIAS, SEFERINO (MD)
Entity Type:Individual
Prefix:
First Name:SEFERINO
Middle Name:
Last Name:FARIAS
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 1:1040 SIERRA DR STE 400
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:12800 MISSISSIPPI PKWY STE C101
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-6901
Practice Address - Country:US
Practice Address - Phone:219-661-0444
Practice Address - Fax:219-226-1222
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053482A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200280620Medicaid
IN1798OtherMEDICARE PTAN
ING29604Medicare UPIN
ING29604Medicare UPIN