Provider Demographics
NPI:1497861090
Name:FAVETTA, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:FAVETTA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1255 BROAD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3061
Mailing Address - Country:US
Mailing Address - Phone:973-707-5632
Mailing Address - Fax:866-806-3675
Practice Address - Street 1:70 RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH ARLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07031-6318
Practice Address - Country:US
Practice Address - Phone:201-997-2332
Practice Address - Fax:201-997-6845
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-11-27
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA03185400207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3037908Medicaid
NJ3037908Medicaid
NJC56249Medicare UPIN