Provider Demographics
NPI:1801818760
Name:FAVALE, DOMINGO CP
Entity Type:Individual
Prefix:
First Name:DOMINGO
Middle Name:CP
Last Name:FAVALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DOMINIC
Other - Middle Name:
Other - Last Name:FAVALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2649 STRANG BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-2938
Mailing Address - Country:US
Mailing Address - Phone:914-739-0087
Mailing Address - Fax:914-737-1714
Practice Address - Street 1:1985 CROMPOND ROAD
Practice Address - Street 2:BLDG D
Practice Address - City:CORTLANDT MANOR
Practice Address - State:NY
Practice Address - Zip Code:10567
Practice Address - Country:US
Practice Address - Phone:914-739-1219
Practice Address - Fax:914-739-2353
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157064208800000X
PAMD478550208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13769OtherAETNA HMO
NY01360925Medicaid
NYWS548OtherOXFORD
NY95F352Medicare PIN
NY13769OtherAETNA HMO
NY01360925Medicaid