Provider Demographics
NPI:1518548288
Name:FARHA, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FARHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 FREESIA CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1972
Mailing Address - Country:US
Mailing Address - Phone:616-304-1042
Mailing Address - Fax:
Practice Address - Street 1:1135 CATHERINE ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-2038
Practice Address - Country:US
Practice Address - Phone:616-304-1042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health