Provider Demographics
NPI:1730304221
Name:FAVILLI, MARIO NOEL (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:NOEL
Last Name:FAVILLI
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 1:4855 W HILLSBORO BLVD
Mailing Address - Street 2:SUITE B8
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4356
Mailing Address - Country:US
Mailing Address - Phone:954-481-2278
Mailing Address - Fax:
Practice Address - Street 1:4855 W HILLSBORO BLVD
Practice Address - Street 2:B8
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4356
Practice Address - Country:US
Practice Address - Phone:954-481-2278
Practice Address - Fax:954-481-1987
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD20948Medicare UPIN
FL04595ZMedicare PIN