Provider Demographics
NPI:1043275761
Name:FARLEY, JOHANN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JOHANN
Middle Name:DAVID
Last Name:FARLEY
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 1:8300 BROADWAY STE D2
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8603
Mailing Address - Country:US
Mailing Address - Phone:219-757-5780
Mailing Address - Fax:219-769-1609
Practice Address - Street 1:8300 BROADWAY STE D2
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8603
Practice Address - Country:US
Practice Address - Phone:219-649-0044
Practice Address - Fax:219-649-0055
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89493207Q00000X
WI46905-20207Q00000X
IN01060680A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200522790Medicaid
IN200522790Medicaid