Provider Demographics
NPI:1922032028
Name:FARRISH, KENNETH (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:FARRISH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4103
Mailing Address - Country:US
Mailing Address - Phone:601-587-1367
Mailing Address - Fax:601-373-2879
Practice Address - Street 1:705 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4103
Practice Address - Country:US
Practice Address - Phone:601-587-1367
Practice Address - Fax:601-373-2879
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80104213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118423Medicaid
MS480000156Medicare ID - Type Unspecified
MST87151Medicare UPIN