Provider Demographics
NPI:1336321835
Name:LUIS C FAVILLI MD LLC
Entity Type:Organization
Organization Name:LUIS C FAVILLI MD LLC
Other - Org Name:FAVILLI FAMILY PRACTICE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAVILLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-285-7171
Mailing Address - Street 1:6675 WESTWOOD BLVD
Mailing Address - Street 2:STE 475
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-8061
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:3650 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4105
Practice Address - Country:US
Practice Address - Phone:863-646-6295
Practice Address - Fax:863-701-2151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056610207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE49325Medicaid
FLK3751Medicare PIN