Provider Demographics
NPI:1093764417
Name:FARLEY, WAYNE L JR (DO)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:L
Last Name:FARLEY
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:642 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:IN
Practice Address - Zip Code:47454-9672
Practice Address - Country:US
Practice Address - Phone:812-723-7450
Practice Address - Fax:812-723-7450
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8031207V00000X
IN02007422A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131883413Medicaid
TX131883415Medicaid
TX131883417Medicaid
IN1101742507OtherANTHEM PTAN
IN300088888Medicaid
TX131883414Medicaid
TX131883418Medicaid
IN163460062OtherMEDICARE PTAN
TX8BD720OtherBCBS