Provider Demographics
NPI:1659577138
Name:DAPHNE L FAVROTH MD AND ASSOCIATES
Entity Type:Organization
Organization Name:DAPHNE L FAVROTH MD AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAPHNE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:FAVROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-669-8400
Mailing Address - Street 1:551 N PLANO RD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-2940
Mailing Address - Country:US
Mailing Address - Phone:972-669-8400
Mailing Address - Fax:972-235-0033
Practice Address - Street 1:551 N PLANO RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2940
Practice Address - Country:US
Practice Address - Phone:972-669-8400
Practice Address - Fax:972-235-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9074207R00000X, 208000000X
LA019205207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179396001Medicaid
TX00484ZMedicare PIN
TX179396001Medicaid