Provider Demographics
NPI:1962509281
Name:FARNSWORTH, MARK BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BRYAN
Last Name:FARNSWORTH
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 1:686 S PIKE ST
Mailing Address - Street 2:
Mailing Address - City:SHINNSTON
Mailing Address - State:WV
Mailing Address - Zip Code:26431-1043
Mailing Address - Country:US
Mailing Address - Phone:304-624-4655
Mailing Address - Fax:681-342-1998
Practice Address - Street 1:RR 4 BOX 315
Practice Address - Street 2:
Practice Address - City:PHILIPPI
Practice Address - State:WV
Practice Address - Zip Code:26416-9591
Practice Address - Country:US
Practice Address - Phone:304-457-5744
Practice Address - Fax:304-457-5758
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0041151000Medicaid
WV0041151000Medicaid
WV080037131Medicare PIN
WV0727101Medicare PIN