Provider Demographics
NPI:1245391754
Name:FAVELA, SAMUEL HUMBERTO JR (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:HUMBERTO
Last Name:FAVELA
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 3157
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79923-3157
Mailing Address - Country:US
Mailing Address - Phone:915-577-0051
Mailing Address - Fax:915-577-0054
Practice Address - Street 1:4532 N MESA ST STE 2A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-6287
Practice Address - Country:US
Practice Address - Phone:915-544-0326
Practice Address - Fax:915-544-2897
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4576-TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127221306Medicaid
TX80300QOtherBLUE CROSS BLUE SHIELD
TX80300QOtherBLUE CROSS BLUE SHIELD
TX127221306Medicaid