Provider Demographics
NPI:1003112798
Name:FAVIS, TYRONE JOHN II (OD)
Entity Type:Individual
Prefix:DR
First Name:TYRONE
Middle Name:JOHN
Last Name:FAVIS
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 NAVAJO TRL
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3756
Mailing Address - Country:US
Mailing Address - Phone:407-625-1930
Mailing Address - Fax:
Practice Address - Street 1:10500 ULMERTON RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-3544
Practice Address - Country:US
Practice Address - Phone:727-444-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL046010704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program