Healthcare Provider Details

I. General information

NPI: 1477663870
Provider Name (Legal Business Name): MARK WILLIAM FARYAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 SUTTER HILL RD
SUTTER CREEK CA
95685-4147
US

IV. Provider business mailing address

20118 NEILSON RD
PINE GROVE CA
95665-9681
US

V. Phone/Fax

Practice location:
  • Phone: 209-267-1011
  • Fax: 209-267-1030
Mailing address:
  • Phone: 209-267-1011
  • Fax: 209-267-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: