Provider Demographics
NPI:1811056252
Name:FARIS, DAVID ALLEN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:FARIS
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 1:1219 JOHNSON AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1353
Mailing Address - Country:US
Mailing Address - Phone:304-842-8888
Mailing Address - Fax:304-842-7629
Practice Address - Street 1:1219 JOHNSON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1353
Practice Address - Country:US
Practice Address - Phone:304-842-8888
Practice Address - Fax:304-842-7629
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV16046207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0095290000Medicaid
WV0665012Medicare ID - Type Unspecified
WV0095290000Medicaid