Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | C1-0010117 | DE |
Y | 207Q00000X | Family Doctor | MD-441587 | PA |
N | 207QS0010X | Family Doctor - Sports Medicine | C1-0010117 | DE |
NPI | 1225205008 |
---|---|
Provider Name | Dr. Kristopher Scott Fayock |
First Address | Philadelphia, PA 19104-5545 |
Second Address | Philadelphia, PA 19104-5545 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2008 |
Last Update Date | 05/12/2016 |