Provider Demographics
NPI:1851485015
Name:FAVEDE, LEON MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:MICHAEL
Last Name:FAVEDE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912-1605
Mailing Address - Country:US
Mailing Address - Phone:740-635-0814
Mailing Address - Fax:740-635-2521
Practice Address - Street 1:100 3RD ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912-1605
Practice Address - Country:US
Practice Address - Phone:740-635-0814
Practice Address - Fax:740-635-2521
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4452/T1108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0979615Medicaid
OH0979615Medicaid
FA0757903Medicare ID - Type Unspecified