Provider Demographics
NPI:1518952407
Name:FAVAZZO, JOSEPH ANGELO (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ANGELO
Last Name:FAVAZZO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3733 PARK EAST DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4338
Mailing Address - Country:US
Mailing Address - Phone:216-245-1290
Mailing Address - Fax:866-571-4884
Practice Address - Street 1:8984 DARROW RD
Practice Address - Street 2:SUITE 2
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-2186
Practice Address - Country:US
Practice Address - Phone:216-245-1290
Practice Address - Fax:866-571-4884
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003320213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2406524Medicaid
OH5315240001OtherDMERC
OH2406524Medicaid