Provider Demographics
NPI:1598722399
Name:FAVILA, EMMANUEL (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:FAVILA
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 1:97 E HALT DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4285
Mailing Address - Country:US
Mailing Address - Phone:812-238-2100
Mailing Address - Fax:812-232-7772
Practice Address - Street 1:97 E HALT DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4285
Practice Address - Country:US
Practice Address - Phone:812-238-2100
Practice Address - Fax:812-232-7772
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039992207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000092869OtherANTHEM BLUE CROSS AND BLUE SHIELD
IN100326580Medicaid
E56626Medicare UPIN
IN100326580Medicaid
IN608850Medicare PIN