Provider Demographics
NPI:1386637676
Name:FAVARA, BLAISE EMILE (MD)
Entity Type:Individual
Prefix:MR
First Name:BLAISE
Middle Name:EMILE
Last Name:FAVARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 W MAIN
Mailing Address - Street 2:SOUTH VALLEY PEDIATRICS
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840
Mailing Address - Country:US
Mailing Address - Phone:406-363-5013
Mailing Address - Fax:406-363-3714
Practice Address - Street 1:1114 W MAIN
Practice Address - Street 2:SOUTH VALLEY PEDIATRICS
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840
Practice Address - Country:US
Practice Address - Phone:406-363-5013
Practice Address - Fax:406-363-3714
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT7843208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
10341OtherBCBS
MT0100487Medicaid
MT0100487Medicaid