Provider Demographics
NPI:1659019826
Name:FARAHAT, PETER M
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:FARAHAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 CAPITAL CIR NE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5517
Mailing Address - Country:US
Mailing Address - Phone:850-765-3748
Mailing Address - Fax:
Practice Address - Street 1:1771 CAPITAL CIR NE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5517
Practice Address - Country:US
Practice Address - Phone:850-765-3748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN277611223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice