Basic Information
| Provider Information | |||||||||
| NPI: | 1134143837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAIRY | ||||||||
| FirstName: | FAROUK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6605 MOSSY ROCK LN | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462372939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177919527 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9015 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462292016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173557700 | ||||||||
| FaxNumber: | 3173559027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01045094A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00140979 | 01 | IN | RR MEDICARE | OTHER | 000000334996 | 01 | IN | ANTHEM | OTHER | 200034460 | 05 | IN | MEDICAID |