Healthcare Provider Details

I. General information

NPI: 1003888207
Provider Name (Legal Business Name): KEVIN JAY FARIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S MAIN ST
NOBLE OK
73068-9623
US

IV. Provider business mailing address

PO BOX 2096
NOBLE OK
73068-2096
US

V. Phone/Fax

Practice location:
  • Phone: 405-872-5403
  • Fax: 405-872-5407
Mailing address:
  • Phone: 405-872-5403
  • Fax: 405-872-5407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberN3025
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16675
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: