Provider Demographics
NPI:1386963536
Name:FARAH, RONDA (MD)
Entity type:Individual
Prefix:
First Name:RONDA
Middle Name:
Last Name:FARAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14500 99TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4730
Mailing Address - Country:US
Mailing Address - Phone:763-898-1570
Mailing Address - Fax:763-898-1576
Practice Address - Street 1:14500 99TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4730
Practice Address - Country:US
Practice Address - Phone:763-898-1570
Practice Address - Fax:763-898-1576
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58018207N00000X
IA40182207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400141467OtherMEDICARE PTAN
MN1386963536Medicaid