Basic Information
| Provider Information | |||||||||
| NPI: | 1417053836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARS | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 813 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076735501 | ||||||||
| FaxNumber: | 3076735434 | ||||||||
| Practice Location | |||||||||
| Address1: | 813 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076735501 | ||||||||
| FaxNumber: | 3076735434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 6773A | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | BF7998923 | 01 | WY | DEA | OTHER | 6773A | 01 | WY | LICENSE | OTHER |