Provider Demographics
NPI:1265494959
Name:FARRA, FREDERIC THOMAS (MD)
Entity type:Individual
Prefix:
First Name:FREDERIC
Middle Name:THOMAS
Last Name:FARRA
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 1:190 CAMPUS BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601
Mailing Address - Country:US
Mailing Address - Phone:540-662-0306
Mailing Address - Fax:540-542-1843
Practice Address - Street 1:190 CAMPUS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-662-0306
Practice Address - Fax:540-542-1843
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041773207RC0000X, 207RI0011X
WV25172207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00656329OtherRAILROAD MEDICARE
000875693OtherWV BLUE SHIELD GROUP #
VA006056954Medicaid
006056954OtherVA MEDICAID PROFESSIONAL
MD550941600OtherMD MEDICAID GROUP
C00085OtherVA MEDICARE B GROUP #
072370OtherANTHEM PROFESSIONAL
MD286101100Medicaid
WV3810003817OtherWV MEDICAID GROUP
08243200000OtherQUALCHOICE PROFESSIONAL
2119636OtherMAMSI PROFESSIONAL
44153OtherSENTARA PROFESSIONAL
001717440OtherWV BLUE SHIELD
WV0085544000Medicaid
P00656329OtherRAILROAD MEDICARE
44153OtherSENTARA PROFESSIONAL
08243200000OtherQUALCHOICE PROFESSIONAL