Provider Demographics
NPI:1508226762
Name:FAVA, TIMOTHY A (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:FAVA
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234-1823
Mailing Address - Country:US
Mailing Address - Phone:860-412-5141
Mailing Address - Fax:860-774-1656
Practice Address - Street 1:450 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:CT
Practice Address - Zip Code:06234-1823
Practice Address - Country:US
Practice Address - Phone:860-412-5141
Practice Address - Fax:860-774-1656
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1629156FX1800X
MA6151156FX1800X
RIOP0035156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician