Provider Demographics
NPI:1659487270
Name:JOHN R FAVETTA M.D., P.A.
Entity Type:Organization
Organization Name:JOHN R FAVETTA M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAVETTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PA
Authorized Official - Phone:201-997-2332
Mailing Address - Street 1:70 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ARLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07031-6318
Mailing Address - Country:US
Mailing Address - Phone:201-997-2332
Mailing Address - Fax:201-997-6845
Practice Address - Street 1:70 RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH ARLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07031-6318
Practice Address - Country:US
Practice Address - Phone:201-997-2332
Practice Address - Fax:201-997-6845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2014-11-18
Deactivation Date:2014-11-04
Deactivation Code:
Reactivation Date:2014-11-18
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03185400207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3037908Medicaid
NJC56249Medicare UPIN
NH3037908Medicaid
NJ1143250001Medicare NSC