Provider Demographics
NPI:1639130024
Name:FAVERO, BRIAN VAL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:VAL
Last Name:FAVERO
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 1:1033 RIVER ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3463
Mailing Address - Country:US
Mailing Address - Phone:810-985-9600
Mailing Address - Fax:810-985-9244
Practice Address - Street 1:1033 RIVER ST
Practice Address - Street 2:SUITE 2
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3463
Practice Address - Country:US
Practice Address - Phone:810-985-9600
Practice Address - Fax:810-985-9244
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBF064615207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M34510001OtherMEDICARE INDIVIDUAL
MI1807400532OtherBLUE CROSS OF MICHIGAN
MI1807400532OtherBLUE CROSS OF MICHIGAN
MIF22553Medicare UPIN