Provider Demographics
NPI:1629072087
Name:FAVA, GEORGE E (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:E
Last Name:FAVA
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 1:1625 FIELDCREST RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-6414
Mailing Address - Country:US
Mailing Address - Phone:717-272-2216
Mailing Address - Fax:
Practice Address - Street 1:875 NORMAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7454
Practice Address - Country:US
Practice Address - Phone:717-272-2010
Practice Address - Fax:717-272-2937
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020892E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B37104Medicare UPIN
118557JD5Medicare ID - Type Unspecified