Provider Demographics
NPI:1972563781
Name:FAY, MARK TERRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TERRENCE
Last Name:FAY
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 1:2640 BIEHN ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1181
Mailing Address - Country:US
Mailing Address - Phone:541-884-3148
Mailing Address - Fax:541-884-3373
Practice Address - Street 1:2640 BIEHN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1181
Practice Address - Country:US
Practice Address - Phone:541-884-3148
Practice Address - Fax:541-884-3373
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58765207W00000X
ORMD16253207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORF2640501647611OtherVISION SERVICE PLAN
ORA002OtherTRICARE
CAXPY094350OtherMEDI-CAL
OR004571003OtherBCBS
OR042937Medicaid
OR180011820OtherRAILROAD MEDICARE
CAXPY094350OtherMEDI-CAL
OR004571003OtherBCBS
ORF2640501647611OtherVISION SERVICE PLAN
ORR00WCHMLBMedicare PIN
ORE68593Medicare UPIN