Provider Demographics
NPI:1790874717
Name:FAVELUKES, ALEX (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:FAVELUKES
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 1:942 SAXON BLVD STE 1A
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8358
Mailing Address - Country:US
Mailing Address - Phone:386-456-5293
Mailing Address - Fax:386-456-5142
Practice Address - Street 1:942 SAXON BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8358
Practice Address - Country:US
Practice Address - Phone:386-456-5293
Practice Address - Fax:386-456-5142
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME957552085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC99454Medicare UPIN