Healthcare Provider Details

I. General information

NPI: 1962509281
Provider Name (Legal Business Name): MARK BRYAN FARNSWORTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 4 BOX 315
PHILIPPI WV
26416-9591
US

IV. Provider business mailing address

686 S PIKE ST
SHINNSTON WV
26431-1043
US

V. Phone/Fax

Practice location:
  • Phone: 304-457-5744
  • Fax: 304-457-5758
Mailing address:
  • Phone: 304-624-4655
  • Fax: 681-342-1998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15126
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: