Provider Demographics
NPI:1205821592
Name:FARR, CHARLES M (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:FARR
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 1:7202 N MILLBROOK AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3341
Mailing Address - Country:US
Mailing Address - Phone:559-435-1750
Mailing Address - Fax:559-450-2108
Practice Address - Street 1:7202 N MILLBROOK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3341
Practice Address - Country:US
Practice Address - Phone:559-435-1750
Practice Address - Fax:559-450-2108
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 45250207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG452500Medicaid
CA770266320OtherEIN
CAOOG452500Medicaid
CAOOG452500Medicaid
CAOOG452500Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER